| Doctor Name: | MR. J. KEVIN ENNISS |
| NPI Number: | 1164485215 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LCSW |
| License Number: | 122189-3501 |
| Business Practice Address: | 6925 Union Park Ctr Suite 490 Midvale, UT - 840474142 |
| Business Phone Number: | 8015662622 |
| Business Fax Number: | 8015660536 |
| Mailing Address: | 1351 Murphys Ln, SALT LAKE CITY |
| State: | UT |
| Postal Code: | 841062931 |
| Phone Number: | 8015662622 |
| Fax Number: | 8015660536 |
| NPI Enumeration Date: | 04/10/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 122189-3501 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | UT |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |