Healthcare Provider Details

I. General information

NPI: 1730747197
Provider Name (Legal Business Name): ANDY LUTHER GENTRY LPC-S; LMFT; LCDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6012 REEF POINT LN STE C
FORT WORTH TX
76135-2056
US

IV. Provider business mailing address

6012 REEF POINT LN STE C
FORT WORTH TX
76135-2056
US

V. Phone/Fax

Practice location:
  • Phone: 682-312-8184
  • Fax:
Mailing address:
  • Phone: 682-312-8184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1882
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number3472
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number3472
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1367
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9272
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: