Provider Demographics
NPI:1154988137
Name:GENTRY, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:GENTRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9957 CROSSPOINT BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3391
Mailing Address - Country:US
Mailing Address - Phone:317-992-1919
Mailing Address - Fax:
Practice Address - Street 1:7550 S MERIDIAN ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-2912
Practice Address - Country:US
Practice Address - Phone:317-992-1919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-24
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN104100000X
106S00000X
IN99112173A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician