Provider Demographics
NPI:1053079400
Name:DRAKE, DEXTER ANTHONY
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:ANTHONY
Last Name:DRAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10166 SKYE SADDLE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89166-6597
Mailing Address - Country:US
Mailing Address - Phone:702-419-0616
Mailing Address - Fax:
Practice Address - Street 1:1333 N BUFFALO DR UNIT 250
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3637
Practice Address - Country:US
Practice Address - Phone:702-507-0373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician