Provider Demographics
NPI:1366635088
Name:ENNIS, DEBORAH (LICSW, LISW-CP)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:ENNIS
Suffix:
Gender:F
Credentials:LICSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1097 S PENDLETON ST STE D
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-1050
Mailing Address - Country:US
Mailing Address - Phone:864-404-7644
Mailing Address - Fax:864-626-0763
Practice Address - Street 1:1097 S PENDLETON ST STE D
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-1050
Practice Address - Country:US
Practice Address - Phone:864-404-7644
Practice Address - Fax:864-626-0763
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC135321041C0700X, 1041C0700X
MA1146001041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0300010OtherMBHP
MA1300881Medicaid