Provider Demographics
NPI:1275851479
Name:DRENTH, GENTRY ROSE (COTA)
Entity Type:Individual
Prefix:
First Name:GENTRY
Middle Name:ROSE
Last Name:DRENTH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:GENTRY
Other - Middle Name:ROSE
Other - Last Name:ROETERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 W SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:PEOTONE
Mailing Address - State:IL
Mailing Address - Zip Code:60468-9545
Mailing Address - Country:US
Mailing Address - Phone:708-710-3312
Mailing Address - Fax:
Practice Address - Street 1:17833 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-782-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-12
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.003230224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant