Healthcare Provider Details

I. General information

NPI: 1144687526
Provider Name (Legal Business Name): ENNISIA TEKEISHA JAMES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ENNISIA HENDERSON

II. Dates (important events)

Enumeration Date: 01/15/2016
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 EAGLES CREST LN
MCDONOUGH GA
30253-4265
US

IV. Provider business mailing address

1700 NORTHSIDE DRIVE NW SUITE A7 UNIT# 5188
ATLANTA GA
30318
US

V. Phone/Fax

Practice location:
  • Phone: 404-694-5469
  • Fax:
Mailing address:
  • Phone: 404-694-5469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006525
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: