Provider Demographics
NPI:1780223073
Name:DRAKE, NICOLE MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N8263 WOODY LN
Mailing Address - Street 2:
Mailing Address - City:IXONIA
Mailing Address - State:WI
Mailing Address - Zip Code:53036-9551
Mailing Address - Country:US
Mailing Address - Phone:414-405-5067
Mailing Address - Fax:
Practice Address - Street 1:354 COTTONWOOD AVE STE C
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2011
Practice Address - Country:US
Practice Address - Phone:262-290-3163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-03
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1315001041C0700X
WI9816-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780223073Medicaid