Basic Information
Provider Information | |||||||||
NPI: | 1043358880 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRAKE | ||||||||
FirstName: | SUSAN | ||||||||
MiddleName: | S | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 271715 | ||||||||
Address2: |   | ||||||||
City: | WEST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061271715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609783368 | ||||||||
FaxNumber: | 8602338110 | ||||||||
Practice Location | |||||||||
Address1: | 17 S HIGHLAND ST | ||||||||
Address2: |   | ||||||||
City: | WEST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061191826 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609783368 | ||||||||
FaxNumber: | 8602338110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/02/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 000888 | CT | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 38520 | 01 | SC | TRICARE | OTHER | 06111 | 01 | CT | OXFORD | OTHER | 22771 | 01 | KY | MHN | OTHER | 87726 | 01 | UT | UNITED BEHAVIORAL | OTHER | 01260 | 01 | MO | MAGELLAN | OTHER | 00060 | 01 | CT | ANTHEM | OTHER | 60054 | 01 | TX | AETNA INSURANCE | OTHER | SX071 | 01 | MN | CIGNA BEHAVIORAL | OTHER |