Provider Demographics
NPI:1407550056
Name:HENDERSON DRAKE, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:HENDERSON DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2204 MOUNT VERNON BLVD
Mailing Address - Street 2:
Mailing Address - City:EAST CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44112-3613
Mailing Address - Country:US
Mailing Address - Phone:216-644-5440
Mailing Address - Fax:
Practice Address - Street 1:1507 SAINT CLAIR AVE NE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2003
Practice Address - Country:US
Practice Address - Phone:216-451-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-28
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator