Provider Demographics
NPI:1790426112
Name:GENTRY, REBEKAH
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:662 DEMING ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3206
Mailing Address - Country:US
Mailing Address - Phone:616-799-1712
Mailing Address - Fax:
Practice Address - Street 1:662 DEMING ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3206
Practice Address - Country:US
Practice Address - Phone:616-799-1712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451022119101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor