Healthcare Provider Details

I. General information

NPI: 1326474933
Provider Name (Legal Business Name): CHARLES JOHN DRAKE III PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44750 60TH ST W
LANCASTER CA
93536-7619
US

IV. Provider business mailing address

44750 60TH ST W
LANCASTER CA
93536-7619
US

V. Phone/Fax

Practice location:
  • Phone: 661-729-2000
  • Fax:
Mailing address:
  • Phone: 661-729-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21245
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: