Provider Demographics
NPI:1164600730
Name:DRADER, JOELLE LYN (MD, MA, LPC)
Entity Type:Individual
Prefix:
First Name:JOELLE
Middle Name:LYN
Last Name:DRADER
Suffix:
Gender:F
Credentials:MD, MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 WAUKAZOO AVE
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2619
Mailing Address - Country:US
Mailing Address - Phone:231-622-5156
Mailing Address - Fax:
Practice Address - Street 1:413 WAUKAZOO AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2619
Practice Address - Country:US
Practice Address - Phone:231-622-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068311208D00000X
MI6401013059101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice