Basic Information
| Provider Information | |||||||||
| NPI: | 1487881967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GENTRY | ||||||||
| FirstName: | STEPHANIE | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 412 FONTAINBLEAU | ||||||||
| Address2: | |||||||||
| City: | O FALLON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622691310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185816958 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2615 EDWARDS ST | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620023915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184622331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2009 | ||||||||
| LastUpdateDate: | 04/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 227010426 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 101YP2500X | 180002447 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.