Provider Demographics
NPI:1609009216
Name:GENTRY, MAYA ELENA I (MSW)
Entity Type:Individual
Prefix:MS
First Name:MAYA
Middle Name:ELENA
Last Name:GENTRY
Suffix:I
Gender:F
Credentials:MSW
Other - Prefix:MS
Other - First Name:MAYA
Other - Middle Name:ELENA
Other - Last Name:GENTRY
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:12771 TIMBER RUN DR
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7430
Mailing Address - Country:US
Mailing Address - Phone:801-842-8915
Mailing Address - Fax:
Practice Address - Street 1:12771 TIMBER RUN DR
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7430
Practice Address - Country:US
Practice Address - Phone:801-842-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-30
Last Update Date:2009-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT259706-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical