Provider Demographics
NPI:1972580348
Name:ENNIS, RICHARD CHRISTOPHER (MSSW, LCSW, LMFT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHRISTOPHER
Last Name:ENNIS
Suffix:
Gender:M
Credentials:MSSW, LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 BAINBRIDGE ROW DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:IRELAND ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-624-9266
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY40291041C0700X
KY0570106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist