=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669573143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN STEWART ENSIGN PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2006
-----------------------------------------------------
Last Update Date | 07/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 433 F ST
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95616-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-304-0711
-----------------------------------------------------
Fax | 530-297-2609
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 433 F ST
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95616-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-304-0711
-----------------------------------------------------
Fax | 530-297-2609
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY14539
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------