Provider Demographics
NPI:1003188806
Name:YATES, KELLEY TERESA (MS OTR/L)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:TERESA
Last Name:YATES
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 PROVIDENCE RD
Mailing Address - Street 2:SUITE 80
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4128
Mailing Address - Country:US
Mailing Address - Phone:757-467-4604
Mailing Address - Fax:757-467-2716
Practice Address - Street 1:5301 PROVIDENCE RD
Practice Address - Street 2:SUITE 80
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4128
Practice Address - Country:US
Practice Address - Phone:757-467-4604
Practice Address - Fax:757-467-2716
Is Sole Proprietor?:No
Enumeration Date:2012-02-08
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119005089225X00000X
NC8647225X00000X
CA16255225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX892T13OtherBLUE CROSS BLUE SHIELD
TX324887401Medicaid
NC7210315Medicaid