1912914383 NPI number — SUZANNE J ENNIS LCSW

Table of content: SUZANNE J ENNIS LCSW (NPI 1912914383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912914383 NPI number — SUZANNE J ENNIS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENNIS
Provider First Name:
SUZANNE
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

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:
1912914383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 BLUEBERRY RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SETAUKET
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11733-1503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-689-8578
Provider Business Mailing Address Fax Number:
631-689-8578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 BLUEBERRY RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SETAUKET
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11733-1503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-689-8578
Provider Business Practice Location Address Fax Number:
631-689-8578
Provider Enumeration Date:
08/01/2006

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:  PR026735 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0008022 . This is a "VALUE OPTIONS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0008022 . This is a "GHI" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01658364 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1052640 . This is a "BEACON HEALTH STRATEGIES" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P2552029 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 12362 . This is a "VYTRA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 182262 . This is a "GUARDIAN PHS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 5861327 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: N1432 . This is a "EMPIRE BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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