Provider Demographics
NPI:1073506556
Name:DRAKE, GARY L
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:L
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 1:3209 SOLUTIONS CTR
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-0001
Mailing Address - Country:US
Mailing Address - Phone:502-212-4759
Mailing Address - Fax:502-471-2051
Practice Address - Street 1:239 MT PARKWAY SPUR
Practice Address - Street 2:
Practice Address - City:CAMPTON
Practice Address - State:KY
Practice Address - Zip Code:41301-0309
Practice Address - Country:US
Practice Address - Phone:606-688-6932
Practice Address - Fax:606-668-3125
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY14291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8200089400Medicaid