Provider Demographics
NPI:1760513113
Name:DRAKE, TERI A (MFT)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:A
Last Name:DRAKE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3415 BRETON AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2709
Mailing Address - Country:US
Mailing Address - Phone:530-758-7163
Mailing Address - Fax:530-758-1021
Practice Address - Street 1:2055 ANDERSON RD
Practice Address - Street 2:SUITE 5
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-0672
Practice Address - Country:US
Practice Address - Phone:530-758-7163
Practice Address - Fax:530-758-1021
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31131101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1952331134OtherNPI-2