Provider Demographics
NPI:1104069384
Name:DRAKE, LINDA GALE
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:GALE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 E RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CORNVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04976-6509
Mailing Address - Country:US
Mailing Address - Phone:207-474-0776
Mailing Address - Fax:207-474-0779
Practice Address - Street 1:1309 E RIDGE RD
Practice Address - Street 2:
Practice Address - City:CORNVILLE
Practice Address - State:ME
Practice Address - Zip Code:04976-6509
Practice Address - Country:US
Practice Address - Phone:207-474-0776
Practice Address - Fax:207-474-0779
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEALLS 2805320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities