Provider Demographics
NPI:1457752925
Name:DRAKE, MALLORY (OTD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:OTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12801 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64145-1229
Mailing Address - Country:US
Mailing Address - Phone:816-752-2358
Mailing Address - Fax:
Practice Address - Street 1:12801 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64145-1229
Practice Address - Country:US
Practice Address - Phone:816-752-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17-02662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist