Provider Demographics
NPI:1417349176
Name:DRAKE, NICHOLAS (LICSW)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27475 GAMBLE BAY RD NE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:WA
Mailing Address - Zip Code:98346-9539
Mailing Address - Country:US
Mailing Address - Phone:517-410-7430
Mailing Address - Fax:
Practice Address - Street 1:27475 GAMBLE BAY RD NE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:WA
Practice Address - Zip Code:98346-9539
Practice Address - Country:US
Practice Address - Phone:517-410-7430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-04
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020881561041C0700X
WA611966561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical