Provider Demographics
NPI:1245835917
Name:ENNIS, MICHELLE MONICA (LICSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MONICA
Last Name:ENNIS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 TOWER RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2038
Mailing Address - Country:US
Mailing Address - Phone:508-746-8426
Mailing Address - Fax:
Practice Address - Street 1:50 TOWER RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2038
Practice Address - Country:US
Practice Address - Phone:508-746-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1215271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty