MEDICARE: MR. PATRICK S ENNIS LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	LCS18208	CA

General Provider Information

NPI Number	:	1457506305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PATRICK S ENNIS LCSW

Provider Business Mailing Address
First Line	:	320 10TH ST
Second Line	:	SUITE 205
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-5291
Country	:	US
Telephone Number	:	707-523-6939
Fax Number	:

Provider Business Practice Location Address
First Line	:	320 10TH ST
Second Line	:	SUITE 205
City	:	SANTA ROSA
State	:	CA
Zip	:	95401-5291
Country	:	US
Telephone Number	:	707-523-6939
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2008
Last Update Date	:	02/11/2022

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