Provider Demographics
NPI:1144371931
Name:DRAKE-DAVID, SELENE MIRANDA (LCSW)
Entity type:Individual
Prefix:
First Name:SELENE
Middle Name:MIRANDA
Last Name:DRAKE-DAVID
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SELENE
Other - Middle Name:
Other - Last Name:DRAKE-DAVID
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 34584
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1584
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7268
Practice Address - Street 1:1730 MINOR AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1498
Practice Address - Country:US
Practice Address - Phone:206-287-2603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099242751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB24200Medicare PIN