Provider Demographics
NPI:1770036188
Name:ENNIS, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
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 1:3556 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-3556
Mailing Address - Country:US
Mailing Address - Phone:805-461-6080
Mailing Address - Fax:
Practice Address - Street 1:3556 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-2532
Practice Address - Country:US
Practice Address - Phone:805-461-6080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst