Provider Demographics
NPI:1376033514
Name:YATES, THLETHA (MED, MS, LPC)
Entity Type:Individual
Prefix:
First Name:THLETHA
Middle Name:
Last Name:YATES
Suffix:
Gender:F
Credentials:MED, MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 TARA COMMONS CIR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8019
Mailing Address - Country:US
Mailing Address - Phone:770-712-3914
Mailing Address - Fax:
Practice Address - Street 1:445 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1707
Practice Address - Country:US
Practice Address - Phone:404-294-3836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-14
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009862101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional