Provider Demographics
NPI:1184820433
Name:ENNIS, AMY L (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:L
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 RICHMOND RD
Mailing Address - Street 2:5K
Mailing Address - City:LIDO BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4845
Mailing Address - Country:US
Mailing Address - Phone:917-549-3491
Mailing Address - Fax:
Practice Address - Street 1:2 RICHMOND RD
Practice Address - Street 2:5K
Practice Address - City:LIDO BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4845
Practice Address - Country:US
Practice Address - Phone:917-549-3491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58-016337235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist