Provider Demographics
NPI:1902474463
Name:DRAKE, TONYA (DPC, LPC, NCC)
Entity Type:Individual
Prefix:DR
First Name:TONYA
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:DPC, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SOUTHPARK DR
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-9784
Mailing Address - Country:US
Mailing Address - Phone:601-456-1669
Mailing Address - Fax:
Practice Address - Street 1:101 SOUTHPARK DR
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-9784
Practice Address - Country:US
Practice Address - Phone:601-456-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2157101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional