Provider Demographics
NPI:1912434762
Name:ENNEKING, REBECCA SARAH (LLMSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:SARAH
Last Name:ENNEKING
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9820 S WISE RD
Mailing Address - Street 2:
Mailing Address - City:SHEPHERD
Mailing Address - State:MI
Mailing Address - Zip Code:48883-9368
Mailing Address - Country:US
Mailing Address - Phone:989-430-1223
Mailing Address - Fax:
Practice Address - Street 1:301 S CRAPO ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2941
Practice Address - Country:US
Practice Address - Phone:989-772-5938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801100910104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker