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NPI Code Detail

MEDICARE: MR. TIMOTHY SHEA ENNISS LCSW

MEDICARE: MR. TIMOTHY SHEA ENNISS LCSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker5664530-3501UT

General Provider Information

NPI Number : 1750487864
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. TIMOTHY SHEA ENNISS LCSW
Provider Business Mailing Address
First Line : 2922 W 12875 S
Second Line :
City : RIVERTON
State : UT
Zip : 84065-6846
Country : US
Telephone Number : 801-979-1305
Fax Number :
Provider Business Practice Location Address
First Line : 1208 E 3300 S
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84106-2522
Country : US
Telephone Number : 801-483-1600
Fax Number : 801-483-1610
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/15/2006
Last Update Date : 04/12/2017

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