Provider Demographics
NPI:1881996320
Name:ENNIS, COLIN (PSYD)
Entity type:Individual
Prefix:DR
First Name:COLIN
Middle Name:
Last Name:ENNIS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N LAKE SHORE DR
Mailing Address - Street 2:515
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-2874
Mailing Address - Country:US
Mailing Address - Phone:312-725-9745
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD
Practice Address - Street 2:635
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3606
Practice Address - Country:US
Practice Address - Phone:312-725-9745
Practice Address - Fax:312-488-3642
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008031103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical