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General NPI Number Information
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NPI Number | 1871859066
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Entity Type | Individual
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Provider Name | GWENDOLYN RENEE DRAKE PSY.D.
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Gender | Female
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Dates
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Enumeration Date | 04/02/2012
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Last Update Date | 10/18/2018
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Provider Practice Location Address
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Address Line | 650 JOEL DR
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City | FORT CAMPBELL
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State | KY
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Zip | 42223-5318
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Country | US
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Telephone | 757-395-0842
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Fax |
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Provider Business Mailing Address
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Address Line | 301 GREEN ST APT 4E
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City | PORTSMOUTH
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State | VA
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Zip | 23704-2470
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Country | US
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Telephone | 757-395-0842
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 0810004452
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License Number State | VA
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