Provider Demographics
NPI:1689180820
Name:DRAKE, TERI (MSW, LSW, ACHP-SW)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:MSW, LSW, ACHP-SW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1234 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2696
Practice Address - Country:US
Practice Address - Phone:419-419-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH14404601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid