Healthcare Provider Details

I. General information

NPI: 1902575376
Provider Name (Legal Business Name): ERIC JOSEPH GENTRY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 PACHECO BLVD
MARTINEZ CA
94553-3625
US

IV. Provider business mailing address

PO BOX 1109
MARTINEZ CA
94553-0110
US

V. Phone/Fax

Practice location:
  • Phone: 925-500-3791
  • Fax:
Mailing address:
  • Phone: 925-500-3791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW132655
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: