Healthcare Provider Details

I. General information

NPI: 1902878101
Provider Name (Legal Business Name): GARY DRAKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BEAUVOIR AVE
SUMMIT NJ
07901-3533
US

IV. Provider business mailing address

PO BOX 23831
NEWARK NJ
07189-0831
US

V. Phone/Fax

Practice location:
  • Phone: 973-971-5595
  • Fax:
Mailing address:
  • Phone: 973-971-5595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC01495500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: