Provider Demographics
NPI:1033251368
Name:GENTRY, TISHA LEA (MA LCPC)
Entity Type:Individual
Prefix:MS
First Name:TISHA
Middle Name:LEA
Last Name:GENTRY
Suffix:
Gender:F
Credentials:MA LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 H YORKSHIRE WAY
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014
Mailing Address - Country:US
Mailing Address - Phone:410-420-7155
Mailing Address - Fax:
Practice Address - Street 1:303 INTERNATIONAL CIR
Practice Address - Street 2:SUITE T-125
Practice Address - City:HUNT VALLEY
Practice Address - State:MD
Practice Address - Zip Code:21030-1464
Practice Address - Country:US
Practice Address - Phone:443-797-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1953101YP2500X
MDLCPC 1953101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health