Provider Demographics
NPI:1578174850
Name:GENTRY, CARSON TYLER
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:TYLER
Last Name:GENTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441-5210
Mailing Address - Country:US
Mailing Address - Phone:785-762-5250
Mailing Address - Fax:
Practice Address - Street 1:814 CAROLINE AVE
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441-5210
Practice Address - Country:US
Practice Address - Phone:785-762-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11839104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker