Provider Demographics
NPI:1811263213
Name:GENTRY, GARDNER RAYE (MS, NCC, LPC)
Entity type:Individual
Prefix:MR
First Name:GARDNER
Middle Name:RAYE
Last Name:GENTRY
Suffix:
Gender:M
Credentials:MS, NCC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 SHUGART RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2467
Mailing Address - Country:US
Mailing Address - Phone:706-270-5107
Mailing Address - Fax:706-270-5102
Practice Address - Street 1:900 SHUGART RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2467
Practice Address - Country:US
Practice Address - Phone:706-270-5107
Practice Address - Fax:706-270-5102
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006756101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional