Provider Demographics
NPI:1770832248
Name:GENTRY, ROBERT ROSS
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ROSS
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 1:298 CLEAR SKY CT STE G
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-5685
Mailing Address - Country:US
Mailing Address - Phone:706-571-7771
Mailing Address - Fax:
Practice Address - Street 1:298 CLEAR SKY CT STE G
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5685
Practice Address - Country:US
Practice Address - Phone:706-571-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA110026265Medicaid