Healthcare Provider Details

I. General information

NPI: 1144944422
Provider Name (Legal Business Name): SHELLEY J DRAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 09/29/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N CENTRAL AVE
KISSIMMEE FL
34741-4450
US

IV. Provider business mailing address

283 PEREGINE DR
INDIALANTIC FL
32903
US

V. Phone/Fax

Practice location:
  • Phone: 407-530-5063
  • Fax:
Mailing address:
  • Phone: 603-557-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: