Provider Demographics
NPI:1902206998
Name:DRAKE, MARLENE
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARLENE
Other - Middle Name:ANN MARIE
Other - Last Name:JEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4310 CAMERON ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3828
Mailing Address - Country:US
Mailing Address - Phone:702-570-5100
Mailing Address - Fax:
Practice Address - Street 1:4310 CAMERON ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3828
Practice Address - Country:US
Practice Address - Phone:702-570-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2018-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1100104100000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner