Provider Demographics
NPI:1407902745
Name:YATES, PHILIP RANDOLPH (PH D)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:RANDOLPH
Last Name:YATES
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4465 BAYMEADOWS RD STE 8
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4727
Mailing Address - Country:US
Mailing Address - Phone:904-731-7222
Mailing Address - Fax:904-731-7406
Practice Address - Street 1:4465 BAYMEADOWS RD STE 8
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4727
Practice Address - Country:US
Practice Address - Phone:904-731-7222
Practice Address - Fax:904-731-7406
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY0002702103T00000X, 103TC1900X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily