Provider Demographics
NPI:1891752846
Name:GENTRY, SUSAN CAROLE (LISW-CP, CSC)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:CAROLE
Last Name:GENTRY
Suffix:
Gender:F
Credentials:LISW-CP, CSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 SURREY CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29212-3139
Mailing Address - Country:US
Mailing Address - Phone:803-551-2900
Mailing Address - Fax:
Practice Address - Street 1:23 SURREY CT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-3139
Practice Address - Country:US
Practice Address - Phone:803-551-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC61961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ32717Medicare ID - Type Unspecified