Provider Demographics
NPI:1275021826
Name:FIELDS, GENTRY
Entity Type:Individual
Prefix:
First Name:GENTRY
Middle Name:
Last Name:FIELDS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4018 W HACKAMORE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-2467
Mailing Address - Country:US
Mailing Address - Phone:602-350-3467
Mailing Address - Fax:
Practice Address - Street 1:4018 W HACKAMORE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85083-2467
Practice Address - Country:US
Practice Address - Phone:602-350-3467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA107152355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant