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General NPI Number Information
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NPI Number | 1851281794
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Entity Type | Individual
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Provider Name | COREY JOHN ENNIS
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Gender | Male
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Dates
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Enumeration Date | 07/03/2025
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Last Update Date | 07/03/2025
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Provider Practice Location Address
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Address Line | 652 BIELENBERG DR STE 103
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City | WOODBURY
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State | MN
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Zip | 55125-4419
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Country | US
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Telephone | 612-430-9181
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Fax |
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Provider Business Mailing Address
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Address Line | 2330 LEXINGTON AVE S APT 206
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City | MENDOTA HEIGHTS
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State | MN
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Zip | 55120-1225
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Country | US
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Telephone | 651-815-9891
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Fax |
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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