MEDICARE: MR. PAUL DOUGLAS DRAKE JR. BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker

General Provider Information

NPI Number	:	1073529111
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL DOUGLAS DRAKE JR. BA

Provider Business Mailing Address
First Line	:	7530 CANTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-1614
Country	:	US
Telephone Number	:	314-726-0464
Fax Number	:	314-382-0952

Provider Business Practice Location Address
First Line	:	7530 CANTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63130-1614
Country	:	US
Telephone Number	:	314-726-0464
Fax Number	:	314-382-0952

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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