Provider Demographics
NPI:1114040490
Name:GENTRY, AMANDA ELIZABETH (LPC)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:GENTRY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 212
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:NC
Mailing Address - Zip Code:28640-0212
Mailing Address - Country:US
Mailing Address - Phone:336-846-7492
Mailing Address - Fax:336-846-7397
Practice Address - Street 1:224 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:NC
Practice Address - Zip Code:28640
Practice Address - Country:US
Practice Address - Phone:336-846-7492
Practice Address - Fax:336-846-7397
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6102328Medicaid
NC1226JOtherBLUECROSS AND BLUESHIELD