Provider Demographics
NPI:1073608444
Name:DRAKE, CAROLYN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6057 WEST ANDREW JOHNSON HIGHWAY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877
Mailing Address - Country:US
Mailing Address - Phone:423-586-9495
Mailing Address - Fax:
Practice Address - Street 1:6057 WEST ANDREW JOHNSON HIGHWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:TALBOTT
Practice Address - State:TN
Practice Address - Zip Code:37877
Practice Address - Country:US
Practice Address - Phone:423-586-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1990235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN446679Medicaid
TN446679Medicare ID - Type UnspecifiedOPT