Provider Demographics
NPI:1922752203
Name:ENBODEN, EMILY MARIE
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:MARIE
Last Name:ENBODEN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:EMILY
Other - Middle Name:MARIE
Other - Last Name:NIEBRUEGGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:208 W POINTE DR STE B
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-8302
Mailing Address - Country:US
Mailing Address - Phone:618-235-3857
Mailing Address - Fax:
Practice Address - Street 1:208 W POINTE DR STE B
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-8302
Practice Address - Country:US
Practice Address - Phone:618-235-3857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178015441101YP2500X
IL180014213101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional