Provider Demographics
NPI:1063644490
Name:DRAKE, KATHERINE
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 E WILLIAMS BLVD
Mailing Address - Street 2:APT. 15107
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-4411
Mailing Address - Country:US
Mailing Address - Phone:714-655-6663
Mailing Address - Fax:
Practice Address - Street 1:5400 E WILLIAMS BLVD
Practice Address - Street 2:APT. 15107
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-4411
Practice Address - Country:US
Practice Address - Phone:714-655-6663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool