Provider Demographics
NPI:1912914383
Name:ENNIS, SUZANNE J (LCSW)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:J
Last Name:ENNIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BLUEBERRY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-1503
Mailing Address - Country:US
Mailing Address - Phone:631-689-8578
Mailing Address - Fax:631-689-8578
Practice Address - Street 1:5 BLUEBERRY RIDGE RD
Practice Address - Street 2:
Practice Address - City:SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-1503
Practice Address - Country:US
Practice Address - Phone:631-689-8578
Practice Address - Fax:631-689-8578
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYPR0267351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0008022OtherVALUE OPTIONS
NY0008022OtherGHI
NY01658364Medicaid
NY1052640OtherBEACON HEALTH STRATEGIES
NYP2552029OtherOXFORD
NY12362OtherVYTRA
NY182262OtherGUARDIAN PHS
NY5861327OtherAETNA
NYN1432OtherEMPIRE BLUE CROSS
NY1052640OtherBEACON HEALTH STRATEGIES
NY0008022OtherVALUE OPTIONS