Provider Demographics
NPI:1063793594
Name:ENNIS, ROBERT E SR (LMSW)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:ENNIS
Suffix:SR
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12190 SILVER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MI
Mailing Address - Zip Code:48418-9001
Mailing Address - Country:US
Mailing Address - Phone:810-233-4031
Mailing Address - Fax:810-237-4141
Practice Address - Street 1:129 E 3RD ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-1728
Practice Address - Country:US
Practice Address - Phone:810-233-4031
Practice Address - Fax:810-237-4141
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801010482101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist