Provider Demographics
NPI:1700517109
Name:ENNO, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ENNO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:VALLEY CITY
Mailing Address - State:ND
Mailing Address - Zip Code:58072-3061
Mailing Address - Country:US
Mailing Address - Phone:701-269-4419
Mailing Address - Fax:
Practice Address - Street 1:415 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:VALLEY CITY
Practice Address - State:ND
Practice Address - Zip Code:58072-3061
Practice Address - Country:US
Practice Address - Phone:701-269-4419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator