Provider Demographics
NPI:1699371534
Name:ENNIS, KASIE
Entity Type:Individual
Prefix:
First Name:KASIE
Middle Name:
Last Name:ENNIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 N WATERVIEW ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98407-5117
Mailing Address - Country:US
Mailing Address - Phone:951-588-5651
Mailing Address - Fax:
Practice Address - Street 1:240 S STADIUM WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4802
Practice Address - Country:US
Practice Address - Phone:951-588-5651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMC60929279101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health