Provider Demographics
NPI:1578174850
Name:GENTRY, CARSON TYLER (LSCSW)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:TYLER
Last Name:GENTRY
Suffix:
Gender:M
Credentials:LSCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4030
Mailing Address - Country:US
Mailing Address - Phone:785-239-3627
Mailing Address - Fax:785-240-8358
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:785-239-3627
Practice Address - Fax:785-240-8358
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS063861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical