Provider Demographics
NPI:1659830388
Name:KATES, AUDREANNA KAY (LMT)
Entity Type:Individual
Prefix:
First Name:AUDREANNA
Middle Name:KAY
Last Name:KATES
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 RALSTON AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-5313
Mailing Address - Country:US
Mailing Address - Phone:419-782-2272
Mailing Address - Fax:419-785-4066
Practice Address - Street 1:1018 RALSTON AVE STE 102
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-5313
Practice Address - Country:US
Practice Address - Phone:419-782-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.023715225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1730575770OtherDR. ALICIA LITTLE, DC