Provider Demographics
NPI:1891169629
Name:DRAKE, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:DRAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 WHAM DR
Mailing Address - Street 2:ROOM 141
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-4313
Mailing Address - Country:US
Mailing Address - Phone:618-453-2361
Mailing Address - Fax:618-453-6130
Practice Address - Street 1:625 WHAM DR
Practice Address - Street 2:ROOM 141
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-4313
Practice Address - Country:US
Practice Address - Phone:618-453-2361
Practice Address - Fax:618-453-6130
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008612103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071008612OtherDEPT. OF FINANCIAL AND PROFESSIONAL REGULATION