Provider Demographics
NPI:1245764745
Name:DRAKE, JOHNNIE
Entity Type:Individual
Prefix:
First Name:JOHNNIE
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 1:1001 HICKORY STREET
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947
Mailing Address - Country:US
Mailing Address - Phone:772-332-5397
Mailing Address - Fax:
Practice Address - Street 1:355 9TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6819
Practice Address - Country:US
Practice Address - Phone:772-770-0077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009349400Medicaid