Provider Demographics
NPI:1871314674
Name:GENTRY, STACEY DEE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:DEE
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 1:15125 LAKEVIEW WAY
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-8135
Mailing Address - Country:US
Mailing Address - Phone:707-245-1131
Mailing Address - Fax:
Practice Address - Street 1:7000B S CENTER DR
Practice Address - Street 2:
Practice Address - City:CLEARLAKE
Practice Address - State:CA
Practice Address - Zip Code:95422-8131
Practice Address - Country:US
Practice Address - Phone:707-274-9101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator