Provider Demographics
NPI:1437285202
Name:DRAKE, KATHLEEN ANN (CADC I NCAC I)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ANN
Last Name:DRAKE
Suffix:
Gender:F
Credentials:CADC I NCAC I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 SW HUME ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4267
Mailing Address - Country:US
Mailing Address - Phone:503-954-4574
Mailing Address - Fax:
Practice Address - Street 1:1508 SW HUME ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-4267
Practice Address - Country:US
Practice Address - Phone:503-954-4574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR06-07-15101YA0400X, 171M00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor