Healthcare Provider Details

I. General information

NPI: 1669573143
Provider Name (Legal Business Name): JOHN STEWART ENSIGN PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 F ST
DAVIS CA
95616-4111
US

IV. Provider business mailing address

433 F ST
DAVIS CA
95616-4111
US

V. Phone/Fax

Practice location:
  • Phone: 530-304-0711
  • Fax: 530-297-2609
Mailing address:
  • Phone: 530-304-0711
  • Fax: 530-297-2609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY14539
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: