Provider Demographics
NPI:1528649613
Name:DRAKE, TANISHA (OTR)
Entity type:Individual
Prefix:
First Name:TANISHA
Middle Name:
Last Name:DRAKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 W 117TH ST APT 5C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1563
Mailing Address - Country:US
Mailing Address - Phone:917-966-0722
Mailing Address - Fax:
Practice Address - Street 1:1919 W MAIN ST
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-5419
Practice Address - Country:US
Practice Address - Phone:917-966-0722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023437225X00000X
NC13900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist