Healthcare Provider Details

I. General information

NPI: 1962919787
Provider Name (Legal Business Name): CHARLENE ANN DRAKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2018
Last Update Date: 01/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 N CROSS POINTE BLVD STE 102
EVANSVILLE IN
47715-9163
US

IV. Provider business mailing address

726 S BENNIGHOF AVE
EVANSVILLE IN
47714-2022
US

V. Phone/Fax

Practice location:
  • Phone: 812-401-1836
  • Fax:
Mailing address:
  • Phone: 503-784-9050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number34008039A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number34008039A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number34008039A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34008039A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: