Healthcare Provider Details

I. General information

NPI: 1982305074
Provider Name (Legal Business Name): KAITLYN YEAGLEY MS, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN MILLARD MS, OTR/L

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 12/25/2023
Certification Date: 12/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5191 ROSEWOOD DR
TRAVERSE CITY MI
49685-9137
US

IV. Provider business mailing address

5191 ROSEWOOD DR
TRAVERSE CITY MI
49685-9137
US

V. Phone/Fax

Practice location:
  • Phone: 231-946-1979
  • Fax: 231-946-1984
Mailing address:
  • Phone: 231-946-1979
  • Fax: 231-946-1984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201011640
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: