Provider Demographics
NPI:1093334310
Name:YATES, PAYTON ALYSE
Entity Type:Individual
Prefix:MS
First Name:PAYTON
Middle Name:ALYSE
Last Name:YATES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 ELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23221-2916
Mailing Address - Country:US
Mailing Address - Phone:276-920-7773
Mailing Address - Fax:
Practice Address - Street 1:2715 DOGTOWN RD
Practice Address - Street 2:
Practice Address - City:GOOCHLAND
Practice Address - State:VA
Practice Address - Zip Code:23063-2424
Practice Address - Country:US
Practice Address - Phone:804-556-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA2204000458235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program