Provider Demographics
NPI:1215359070
Name:DRAKE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:105 S GARDEN AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 S GARDEN AVENUE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156
Practice Address - Country:US
Practice Address - Phone:509-447-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH00011090101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health