MEDICARE: MS. KACY YVETTE TATE OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OT13155	FL
2	225X00000X	Occupational Therapist	OT003586	GA

General Provider Information

NPI Number	:	1174785943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KACY YVETTE TATE OTR/L

Provider Business Mailing Address
First Line	:	1173 RIVERSIDE TER
Second Line	:
City	:	GAINESVILLE
State	:	GA
Zip	:	30501-1735
Country	:	US
Telephone Number	:	770-536-9573
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 SW 16TH ST
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32608-1128
Country	:	US
Telephone Number	:	352-376-8821
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	07/01/2008

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