Healthcare Provider Details

I. General information

NPI: 1104532621
Provider Name (Legal Business Name): PHILIP GERARD GENTILE JD, MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: PHILIP G GENTILE JD, MDW

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6258 ROUTE 209
STROUDSBURG PA
18360-7159
US

IV. Provider business mailing address

PO BOX 1698
BETHLEHEM PA
18016-1698
US

V. Phone/Fax

Practice location:
  • Phone: 610-653-6993
  • Fax:
Mailing address:
  • Phone: 610-653-6993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: