Provider Demographics
NPI:1932920212
Name:DRAKE, STACI L (EDS ; NASP)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:L
Last Name:DRAKE
Suffix:
Gender:F
Credentials:EDS ; NASP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-4149
Mailing Address - Country:US
Mailing Address - Phone:740-601-1736
Mailing Address - Fax:
Practice Address - Street 1:8735 INDIAN CREEK RD S
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46259-1330
Practice Address - Country:US
Practice Address - Phone:317-803-5987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10269045103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool