Provider Demographics
NPI:1649335944
Name:GENTRY, TERESA HOLT (MACCC-A)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:HOLT
Last Name:GENTRY
Suffix:
Gender:F
Credentials:MACCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N POINT PKWY
Mailing Address - Street 2:STE 130
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5210
Mailing Address - Country:US
Mailing Address - Phone:678-206-2589
Mailing Address - Fax:678-261-1713
Practice Address - Street 1:2365 OLD MILTON PKWY
Practice Address - Street 2:STE 300
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2140
Practice Address - Country:US
Practice Address - Phone:770-740-1860
Practice Address - Fax:678-347-2104
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003286231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA139558Medicaid