Provider Demographics
NPI:1871396663
Name:DE ATLEY, TATE LEVI (CMT)
Entity type:Individual
Prefix:MR
First Name:TATE
Middle Name:LEVI
Last Name:DE ATLEY
Suffix:
Gender:
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1897 L ST LOT 10
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6902
Mailing Address - Country:US
Mailing Address - Phone:317-689-9894
Mailing Address - Fax:
Practice Address - Street 1:814 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6598
Practice Address - Country:US
Practice Address - Phone:907-487-9798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK236925225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist