Provider Demographics
NPI:1740304476
Name:ENNIS, KIMBERLY RENEE (LCSW)
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:RENEE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:KIMBERLY
Other - Middle Name:RENEE
Other - Last Name:SULECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:75 HAMPSTEAD VLG
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-8250
Mailing Address - Country:US
Mailing Address - Phone:910-270-3811
Mailing Address - Fax:910-270-3897
Practice Address - Street 1:75 HAMPSTEAD VLG
Practice Address - Street 2:
Practice Address - City:HAMPSTEAD
Practice Address - State:NC
Practice Address - Zip Code:28443-8250
Practice Address - Country:US
Practice Address - Phone:910-270-3811
Practice Address - Fax:910-270-3897
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0039791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC186473OtherMEDCOST
NC6002279Medicaid
NC130XROtherBCBS