Provider Demographics
NPI:1780602565
Name:GENTRY, WILLIAM ALLEN (MPT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:ALLEN
Last Name:GENTRY
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 TRANSIT AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-2544
Mailing Address - Country:US
Mailing Address - Phone:770-721-8160
Mailing Address - Fax:770-721-8173
Practice Address - Street 1:720 TRANSIT AVE STE 202
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-2544
Practice Address - Country:US
Practice Address - Phone:770-721-8160
Practice Address - Fax:770-721-8173
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT008896225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA017104C95Medicare ID - Type Unspecified