Healthcare Provider Details

I. General information

NPI: 1376620864
Provider Name (Legal Business Name): ELLEN L. GENTNER PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W CITRUS ST
ALTAMONTE SPRINGS FL
32714-2502
US

IV. Provider business mailing address

108 W CITRUS ST
ALTAMONTE SPRINGS FL
32714-2502
US

V. Phone/Fax

Practice location:
  • Phone: 407-682-6330
  • Fax: 407-682-5972
Mailing address:
  • Phone: 407-682-6330
  • Fax: 407-682-5972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY0003704
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: