Healthcare Provider Details

I. General information

NPI: 1376139691
Provider Name (Legal Business Name): MRS. YVONNE VICTORIA BATES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 W MAIN ST
WATERTOWN NY
13601-1381
US

IV. Provider business mailing address

32714 RAILROAD STREET
GREAT BEND NY
13643
US

V. Phone/Fax

Practice location:
  • Phone: 315-788-1530
  • Fax:
Mailing address:
  • Phone: 915-861-4738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: