Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225X00000X | Occupational Therapist | 0119005089 | VA |
N | 225X00000X | Occupational Therapist | 16255 | CA |
N | 225X00000X | Occupational Therapist | 8647 | NC |
NPI | 1003188806 |
---|---|
Provider Name | Ms. Kelley Teresa Yates |
First Address | Virginia Beach, VA 23464-4128 |
Second Address | Virginia Beach, VA 23464-4128 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2012 |
Last Update Date | 14/06/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
324887401 | (05) | TX |
7210315 | (05) | NC |
892T13 | BLUE CROSS BLUE SHIELD (01) | TX |