Provider Demographics
NPI:1023035474
Name:DRAKE, LIZA JAYNE (LCSW)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:JAYNE
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 1:7432 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53213-3655
Mailing Address - Country:US
Mailing Address - Phone:414-807-3477
Mailing Address - Fax:
Practice Address - Street 1:W4051 COUNTY ROAD NN
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-4338
Practice Address - Country:US
Practice Address - Phone:262-741-3200
Practice Address - Fax:262-741-3315
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI72201231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00264098OtherRAILROAD MEDICARE
WI40914700Medicaid
WI000652520Medicare ID - Type UnspecifiedPART B
WI000701823Medicare ID - Type Unspecified