Provider Demographics
NPI:1295943470
Name:ENNIS, AMY MARIE (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
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 1:640 PHILLIPS DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-6058
Mailing Address - Country:US
Mailing Address - Phone:469-948-0847
Mailing Address - Fax:
Practice Address - Street 1:640 PHILLIPS DR
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-6058
Practice Address - Country:US
Practice Address - Phone:469-948-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19815235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist