Healthcare Provider Details

I. General information

NPI: 1518588003
Provider Name (Legal Business Name): RAE DANETT DRACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 CORNELL RD
LATHAM NY
12110-1491
US

IV. Provider business mailing address

15 CORNELL RD
LATHAM NY
12110-1491
US

V. Phone/Fax

Practice location:
  • Phone: 518-510-3100
  • Fax:
Mailing address:
  • Phone: 518-510-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number25276
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: