Basic Information
| Provider Information | |||||||||
| NPI: | 1003188806 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YATES | ||||||||
| FirstName: | KELLEY | ||||||||
| MiddleName: | TERESA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | M.S. OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 PROVIDENCE RD | ||||||||
| Address2: | SUITE 80 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234644128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674604 | ||||||||
| FaxNumber: | 7574672716 | ||||||||
| Practice Location | |||||||||
| Address1: | 5301 PROVIDENCE RD | ||||||||
| Address2: | SUITE 80 | ||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234644128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674604 | ||||||||
| FaxNumber: | 7574672716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2012 | ||||||||
| LastUpdateDate: | 06/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 0119005089 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 8647 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225X00000X | 16255 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 892T13 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 324887401 | 05 | TX | MEDICAID | 7210315 | 05 | NC | MEDICAID |