Provider Demographics
NPI:1003839887
Name:GENTRY, WILLIAM RAYBURN JR (PHD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:RAYBURN
Last Name:GENTRY
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1922 EXETER RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2949
Mailing Address - Country:US
Mailing Address - Phone:901-754-9688
Mailing Address - Fax:901-754-8630
Practice Address - Street 1:1922 EXETER RD
Practice Address - Street 2:SUITE 7
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2949
Practice Address - Country:US
Practice Address - Phone:901-754-9688
Practice Address - Fax:901-754-8630
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNP636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3684912Medicaid
TN3984947Medicaid
TN3984947Medicaid
TN3984947Medicare ID - Type UnspecifiedPSYCHOLOGIST-GROUP