Provider Demographics
NPI:1407257785
Name:DRAKE, NICOLE (LPC, LCADC, ACS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:LPC, LCADC, ACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 GREEN GROVE AVE
Mailing Address - Street 2:#2
Mailing Address - City:KEYPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:07735-1839
Mailing Address - Country:US
Mailing Address - Phone:908-693-5279
Mailing Address - Fax:
Practice Address - Street 1:36 GREEN GROVE AVE
Practice Address - Street 2:#2
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1839
Practice Address - Country:US
Practice Address - Phone:908-693-5279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00157100101YA0400X
NJ37PC00452300101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)