Provider Demographics
NPI:1811939663
Name:GENTRY, JOHN MARCELLO (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARCELLO
Last Name:GENTRY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:928 JAYMOR RD
Mailing Address - Street 2:SUITE B-150
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3826
Mailing Address - Country:US
Mailing Address - Phone:215-947-8654
Mailing Address - Fax:215-938-7607
Practice Address - Street 1:928 JAYMOR RD
Practice Address - Street 2:SUITE B-150
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-3826
Practice Address - Country:US
Practice Address - Phone:215-947-8654
Practice Address - Fax:215-938-7607
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS004299L103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent