Provider Demographics
NPI:1225335672
Name:YATES, GARY ALAN (LADC)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ALAN
Last Name:YATES
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 DONAHOE DR
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2919
Mailing Address - Country:US
Mailing Address - Phone:580-716-9284
Mailing Address - Fax:
Practice Address - Street 1:201 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-4311
Practice Address - Country:US
Practice Address - Phone:580-763-0931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-22
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK766101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)