Provider Demographics
NPI:1619710076
Name:GENTRY, ZACKARY HAWTHORNE (LCSW)
Entity type:Individual
Prefix:
First Name:ZACKARY
Middle Name:HAWTHORNE
Last Name:GENTRY
Suffix:
Gender:X
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 ADAMS ST APT 6
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02122-1929
Mailing Address - Country:US
Mailing Address - Phone:469-618-3509
Mailing Address - Fax:
Practice Address - Street 1:199 WELLS AVE
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02459-3325
Practice Address - Country:US
Practice Address - Phone:774-519-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW230274104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker