Healthcare Provider Details

I. General information

NPI: 1063793594
Provider Name (Legal Business Name): ROBERT E ENNIS SR. LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 E 3RD ST
FLINT MI
48502-1728
US

IV. Provider business mailing address

12190 SILVER LAKE RD
BYRON MI
48418-9001
US

V. Phone/Fax

Practice location:
  • Phone: 810-233-4031
  • Fax: 810-237-4141
Mailing address:
  • Phone: 810-233-4031
  • Fax: 810-237-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6801010482
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6801010482
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801010482
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6801010482
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6801010482
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: