Healthcare Provider Details

I. General information

NPI: 1013540277
Provider Name (Legal Business Name): FHE'LYCIA M ENNIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 ADAMS ST STE C25
RIVERSIDE CA
92504-8312
US

IV. Provider business mailing address

501 SHATTO PL STE 100
LOS ANGELES CA
90020-1747
US

V. Phone/Fax

Practice location:
  • Phone: 888-428-3223
  • Fax: 323-866-1881
Mailing address:
  • Phone: 888-428-3223
  • Fax: 323-866-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number01-19-35889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: