Healthcare Provider Details

I. General information

NPI: 1982983037
Provider Name (Legal Business Name): KIMBERLY ANN DRAKE OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2011
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 ALEXANDER ST
FAYETTEVILLE NC
28301-5752
US

IV. Provider business mailing address

816 FAIRFIELD CIR
RAEFORD NC
28376-6722
US

V. Phone/Fax

Practice location:
  • Phone: 910-920-1068
  • Fax:
Mailing address:
  • Phone: 419-575-7961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number7977
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: