Provider Demographics
NPI:1871007153
Name:ENNIS, PATRICIA GRACE (MOTR/L)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:GRACE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:GRACE
Other - Last Name:ANTCLIFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:511 LACEBARK DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-5751
Mailing Address - Country:US
Mailing Address - Phone:757-876-2796
Mailing Address - Fax:
Practice Address - Street 1:1071 THOMAS AVE
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6073
Practice Address - Country:US
Practice Address - Phone:706-224-9154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-26
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT005419225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty