1164595443 NPI number — GEORGE M ENNELS LCSW

Table of content: GEORGE M ENNELS LCSW (NPI 1164595443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164595443 NPI number — GEORGE M ENNELS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENNELS
Provider First Name:
GEORGE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164595443
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 GREAT BRIDGE BLVD
Provider Second Line Business Mailing Address:
CITY OF CHESAPEAKE TA CHESAPEAKE COMM. SERV. BOARD
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320-3904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-547-9334
Provider Business Mailing Address Fax Number:
757-819-6292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 GREAT BRIDGE BLVD
Provider Second Line Business Practice Location Address:
CITY OF CHESAPEAKE TA CHESAPEAKE COMM. SERV. BOARD
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-3904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-547-9334
Provider Business Practice Location Address Fax Number:
757-819-6292
Provider Enumeration Date:
11/16/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  0904000980 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 088100 . This is a "TRIGON" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 325673 . This is a "MAMSI" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".