Provider Demographics
NPI:1720140700
Name:DRAKE, MARY ANN (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3495 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-1860
Mailing Address - Country:US
Mailing Address - Phone:478-477-4399
Mailing Address - Fax:
Practice Address - Street 1:1549 COLEMAN AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1517
Practice Address - Country:US
Practice Address - Phone:478-361-1848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA00856103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBCKLMedicare ID - Type UnspecifiedPSYCH