Basic Information
| Provider Information | |||||||||
| NPI: | 1336563667 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YATES | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23 N CHESTER ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212311626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703148315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2014 | ||||||||
| LastUpdateDate: | 02/06/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1730 | KY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.