Provider Demographics
NPI:1174047856
Name:GENTRY, GREGORY H (LAC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:H
Last Name:GENTRY
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 SANDEFUR DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3245
Mailing Address - Country:US
Mailing Address - Phone:318-752-4454
Mailing Address - Fax:
Practice Address - Street 1:2000 FAIRFILED AVENUE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2002
Practice Address - Country:US
Practice Address - Phone:318-222-8511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA116101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA116OtherADDICTIVE DISORDER REGULATORY AUTHORITY