Provider Demographics
NPI:1669697223
Name:GENTRY, NICHOLUS
Entity type:Individual
Prefix:
First Name:NICHOLUS
Middle Name:
Last Name:GENTRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:NICK
Other - Middle Name:
Other - Last Name:GENTRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1790 SELAH LOOP ROAD #23
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942
Mailing Address - Country:US
Mailing Address - Phone:509-452-7418
Mailing Address - Fax:
Practice Address - Street 1:1790 SELAH LOOP ROAD #23
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942
Practice Address - Country:US
Practice Address - Phone:509-452-7418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health