Provider Demographics
NPI:1750487864
Name:ENNISS, TIMOTHY SHEA (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:SHEA
Last Name:ENNISS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2922 W 12875 S
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84065-6846
Mailing Address - Country:US
Mailing Address - Phone:801-979-1305
Mailing Address - Fax:
Practice Address - Street 1:1208 E 3300 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2522
Practice Address - Country:US
Practice Address - Phone:801-483-1600
Practice Address - Fax:801-483-1610
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5664530-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical