Provider Demographics
NPI:1760894737
Name:DRAKE, LYLE (AUD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 GEORGIAN PARK
Mailing Address - Street 2:STE 100
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-6968
Mailing Address - Country:US
Mailing Address - Phone:770-955-0270
Mailing Address - Fax:770-955-0271
Practice Address - Street 1:2080 NEWNAN CROSSING BLVD
Practice Address - Street 2:SUITE 300
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-955-0270
Practice Address - Fax:770-955-0271
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003964231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist