Basic Information
| Provider Information | |||||||||
| NPI: | 1295884849 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENNIS | ||||||||
| FirstName: | LEROY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GLENCAR AVE | ||||||||
| Address2: | APT. 40 | ||||||||
| City: | NEW ROCHELLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 108012337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142376089 | ||||||||
| FaxNumber: | 9142376099 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 BRONX RIVER RD STE 204 | ||||||||
| Address2: | C/O WJCS - FAMILY MATTERS PROGRAM | ||||||||
| City: | YONKERS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 107041752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142376089 | ||||||||
| FaxNumber: | 9142376099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 079975 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.