Healthcare Provider Details

I. General information

NPI: 1033251368
Provider Name (Legal Business Name): TISHA LEA GENTRY MA LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 INTERNATIONAL CIR SUITE T-125
HUNT VALLEY MD
21030-1464
US

IV. Provider business mailing address

203 H YORKSHIRE WAY
BEL AIR MD
21014
US

V. Phone/Fax

Practice location:
  • Phone: 443-797-0144
  • Fax:
Mailing address:
  • Phone: 410-420-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC 1953
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC1953
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: