Provider Demographics
NPI:1790523405
Name:DRAKE, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:846 HASENFLU DR
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-2825
Mailing Address - Country:US
Mailing Address - Phone:845-649-3047
Mailing Address - Fax:
Practice Address - Street 1:121 HAVERSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-4610
Practice Address - Country:US
Practice Address - Phone:814-308-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP010555224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty