Provider Demographics
NPI:1386972446
Name:ENNIS, BRENDA MARIE (MSW; DCSW)
Entity type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:MARIE
Last Name:ENNIS
Suffix:
Gender:F
Credentials:MSW; DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2202 MITCHELL PARK DR
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-8897
Mailing Address - Country:US
Mailing Address - Phone:231-487-1750
Mailing Address - Fax:231-487-1754
Practice Address - Street 1:2202 MITCHELL PARK DR
Practice Address - Street 2:SUITE 2B
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8897
Practice Address - Country:US
Practice Address - Phone:231-487-1750
Practice Address - Fax:231-487-1754
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010855341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical