Provider Demographics
NPI:1710234968
Name:STEVENS, GENTRY (AS, BA)
Entity Type:Individual
Prefix:MR
First Name:GENTRY
Middle Name:
Last Name:STEVENS
Suffix:
Gender:M
Credentials:AS, BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9127 OXFORD PIKE
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47012-7874
Mailing Address - Country:US
Mailing Address - Phone:765-647-4173
Mailing Address - Fax:
Practice Address - Street 1:9127 OXFORD PIKE
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:IN
Practice Address - Zip Code:47012-7874
Practice Address - Country:US
Practice Address - Phone:765-647-4173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical