Provider Demographics
NPI:1942728894
Name:GENTRY, CAROLINE STANLY (LPC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLINE
Middle Name:STANLY
Last Name:GENTRY
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:LINA
Other - Middle Name:STANLY
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:8313 GREELEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-2905
Mailing Address - Country:US
Mailing Address - Phone:314-873-1717
Mailing Address - Fax:
Practice Address - Street 1:8304 OLD KEENE MILL RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22152-1640
Practice Address - Country:US
Practice Address - Phone:314-873-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007248101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0701007248Medicaid