Provider Demographics
NPI:1114032356
Name:DRAKE, STACEY S (LCSW)
Entity Type:Individual
Prefix:MS
First Name:STACEY
Middle Name:S
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 1:7717 ELON DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-1432
Mailing Address - Country:US
Mailing Address - Phone:919-818-1459
Mailing Address - Fax:
Practice Address - Street 1:8520 SIX FORKS RD
Practice Address - Street 2:104
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3095
Practice Address - Country:US
Practice Address - Phone:919-818-1459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0007241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003639Medicaid