MEDICARE: MARCUS LONDYN DRAKE

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	103K00000X	Behavior Analyst	2106114604	NE
2	106E00000X	Assistant Behavior Analyst	2106114604	NV

General Provider Information

NPI Number	:	1477156040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCUS LONDYN DRAKE

Provider Business Mailing Address
First Line	:	5370 E CRAIG RD APT 1187
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-2510
Country	:	US
Telephone Number	:	563-639-9823
Fax Number	:

Provider Business Practice Location Address
First Line	:	4185 VEGAS VALLEY DR STE B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-2522
Country	:	US
Telephone Number	:	702-463-9066
Fax Number	:	702-463-9067

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

Provider Enumeration Date	:	11/17/2020
Last Update Date	:	11/17/2020

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Directions to “ MARCUS LONDYN DRAKE ” Practice Location

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