Provider Demographics
NPI:1346581097
Name:GENTRY PEDIATRIC BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:GENTRY PEDIATRIC BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:GENTRY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, BCBA-D
Authorized Official - Phone:602-312-2911
Mailing Address - Street 1:7600 N 16TH ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4431
Mailing Address - Country:US
Mailing Address - Phone:602-312-2911
Mailing Address - Fax:
Practice Address - Street 1:7600 N 16TH ST
Practice Address - Street 2:SUITE 218
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-4431
Practice Address - Country:US
Practice Address - Phone:602-312-2911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBA-15103K00000X
AZ3913103T00000X
103TB0200X, 103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty