Provider Demographics
NPI:1023370889
Name:GENTRY, LORENE (MSED)
Entity Type:Individual
Prefix:MS
First Name:LORENE
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 MEDEA WAY
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4540
Mailing Address - Country:US
Mailing Address - Phone:917-532-8267
Mailing Address - Fax:
Practice Address - Street 1:273 MEDEA WAY
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4540
Practice Address - Country:US
Practice Address - Phone:917-532-8267
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency