Provider Demographics
NPI:1174197933
Name:GENTILE, CLARK RAYMOND
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:RAYMOND
Last Name:GENTILE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MARINE AVE APT 6D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7545
Mailing Address - Country:US
Mailing Address - Phone:718-954-0852
Mailing Address - Fax:
Practice Address - Street 1:159 20TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-1253
Practice Address - Country:US
Practice Address - Phone:646-685-4422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015535101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty