Provider Demographics
NPI:1194076109
Name:DRAKE, TASHA RENEE (PT)
Entity type:Individual
Prefix:MRS
First Name:TASHA
Middle Name:RENEE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:TASHA
Other - Middle Name:RENEE
Other - Last Name:MIRONENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1225 W LAKE ST
Mailing Address - Street 2:OUTPATIENT PHYSICAL THERAPY
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-4039
Mailing Address - Country:US
Mailing Address - Phone:708-938-7262
Mailing Address - Fax:708-938-7955
Practice Address - Street 1:1111 SUPERIOR ST
Practice Address - Street 2:LL
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-4138
Practice Address - Country:US
Practice Address - Phone:708-938-7408
Practice Address - Fax:708-938-7955
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.011252225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist