Provider Demographics
NPI:1932364007
Name:WAKE, CASEY (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:
Last Name:WAKE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5810 RALSTON ST
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5908
Mailing Address - Country:US
Mailing Address - Phone:805-796-7637
Mailing Address - Fax:
Practice Address - Street 1:5810 RALSTON ST FL 2
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5908
Practice Address - Country:US
Practice Address - Phone:805-642-7033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 101YP2500X
CAPSY28390103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7420Medicaid
CA7068Medicaid