Provider Demographics
NPI:1245650142
Name:DRAKE, LISA ANN
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DRAKE
Other - Last Name:KRUZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLPC
Mailing Address - Street 1:424 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOYNE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49712-1310
Mailing Address - Country:US
Mailing Address - Phone:231-622-2421
Mailing Address - Fax:
Practice Address - Street 1:424 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BOYNE CITY
Practice Address - State:MI
Practice Address - Zip Code:49712-1310
Practice Address - Country:US
Practice Address - Phone:231-622-2421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013883101YS0200X
6401013883101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool