Healthcare Provider Details

I. General information

NPI: 1679274146
Provider Name (Legal Business Name): COURTNEY GENTRY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 W TECH BLVD
MIAMISBURG OH
45342-4865
US

IV. Provider business mailing address

PO BOX 933421
CLEVELAND OH
44193-0039
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-4040
  • Fax: 937-641-3066
Mailing address:
  • Phone: 937-641-5072
  • Fax: 937-641-6129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2512142
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: