Provider Demographics
NPI:1356714430
Name:ENNIS, KEITH MCPHERSON (SUDC III-CS)
Entity type:Individual
Prefix:MR
First Name:KEITH
Middle Name:MCPHERSON
Last Name:ENNIS
Suffix:
Gender:M
Credentials:SUDC III-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 N. FIRST ST. # 135
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726
Mailing Address - Country:US
Mailing Address - Phone:559-225-1464
Mailing Address - Fax:559-225-1693
Practice Address - Street 1:3636 N 1ST ST STE 135&154
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726-6800
Practice Address - Country:US
Practice Address - Phone:559-225-1464
Practice Address - Fax:559-225-1693
Is Sole Proprietor?:No
Enumeration Date:2015-11-11
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6533101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)