Provider Demographics
NPI:1922248541
Name:ENNIS, AUDREY J (MSW, LSW)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:J
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2541
Mailing Address - Country:US
Mailing Address - Phone:610-565-2646
Mailing Address - Fax:
Practice Address - Street 1:6 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-2541
Practice Address - Country:US
Practice Address - Phone:610-565-2646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-21
Last Update Date:2009-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW1268411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical