Healthcare Provider Details

I. General information

NPI: 1609417450
Provider Name (Legal Business Name): TRAVIS PAUL DRAKE LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LARKWOOD DR
MT STERLING KY
40353-8847
US

IV. Provider business mailing address

1200 LARKWOOD DR
MT STERLING KY
40353-8847
US

V. Phone/Fax

Practice location:
  • Phone: 606-481-1609
  • Fax:
Mailing address:
  • Phone: 606-481-1609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number283015
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number260120
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: