Provider Demographics
NPI:1194513804
Name:DEITCH, DRAKE
Entity type:Individual
Prefix:
First Name:DRAKE
Middle Name:
Last Name:DEITCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 W VAN BUREN ST APT 203
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2804
Mailing Address - Country:US
Mailing Address - Phone:248-410-4789
Mailing Address - Fax:248-410-4789
Practice Address - Street 1:737 N MICHIGAN AVE STE 1925
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-5422
Practice Address - Country:US
Practice Address - Phone:312-283-2650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178014164101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health