Healthcare Provider Details

I. General information

NPI: 1346581097
Provider Name (Legal Business Name): GENTRY PEDIATRIC BEHAVIORAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 03/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 N 16TH ST SUITE 218
PHOENIX AZ
85020-4431
US

IV. Provider business mailing address

7600 N 16TH ST SUITE 218
PHOENIX AZ
85020-4431
US

V. Phone/Fax

Practice location:
  • Phone: 602-312-2911
  • Fax:
Mailing address:
  • Phone: 602-312-2911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number3913
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberBA-15
License Number StateAZ

VIII. Authorized Official

Name: DR. JOSEPH GENTRY
Title or Position: PRESIDENT/CEO
Credential: PH.D., BCBA-D
Phone: 602-312-2911