Basic Information
| Provider Information | |||||||||
| NPI: | 1033407747 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENSMAN | ||||||||
| FirstName: | KELLI | ||||||||
| MiddleName: | EVELYN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 850 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264841003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 EAST FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094214633 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 08/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 87562 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.