Provider Demographics
NPI:1912236118
Name:YATES, RANDALL GLENN (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:GLENN
Last Name:YATES
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 WAYMONT CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6748
Mailing Address - Country:US
Mailing Address - Phone:407-833-2729
Mailing Address - Fax:
Practice Address - Street 1:290 WAYMONT CT
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6748
Practice Address - Country:US
Practice Address - Phone:407-833-2729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-17
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT12547225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics