Provider Demographics
NPI:1811725120
Name:ENNIS, STEPHANIE ELLEN
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELLEN
Last Name:ENNIS
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 1:27 SENTINEL DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-2600
Mailing Address - Country:US
Mailing Address - Phone:330-321-1943
Mailing Address - Fax:
Practice Address - Street 1:120 E UWCHLAN AVE
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-1275
Practice Address - Country:US
Practice Address - Phone:610-524-8701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002098103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst