Provider Demographics
NPI:1003081431
Name:DRAKE, REBECCA ANN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:REBECCA
Middle Name:ANN
Last Name:DRAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 PELICAN CT
Mailing Address - Street 2:
Mailing Address - City:SURF CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28445-6952
Mailing Address - Country:US
Mailing Address - Phone:910-328-4872
Mailing Address - Fax:
Practice Address - Street 1:200 TARPON TRAIL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5226
Practice Address - Country:US
Practice Address - Phone:910-328-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-27
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC004558101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD206391300Medicaid
665373Medicare UPIN