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General NPI Number Information
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NPI Number | 1063793594
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Entity Type | Individual
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Provider Name | ROBERT E ENNIS SR. LMSW
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Gender | Male
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Dates
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Enumeration Date | 08/29/2011
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Last Update Date | 08/29/2011
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Provider Practice Location Address
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Address Line | 129 E 3RD ST
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City | FLINT
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State | MI
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Zip | 48502-1728
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Country | US
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Telephone | 810-233-4031
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Fax | 810-237-4141
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Provider Business Mailing Address
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Address Line | 12190 SILVER LAKE RD
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City | BYRON
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State | MI
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Zip | 48418-9001
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Country | US
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Telephone | 810-233-4031
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Fax | 810-237-4141
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 6801010482
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 6801010482
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 6801010482
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6801010482
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License Number State | MI
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Taxonomy #5
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 6801010482
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License Number State | MI
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