Active NPI
Chad Drake
- Clinical Psychologist
- Carbondale, IL
National Provider Identifier
1891169629
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- 071008612
- Practice address
- 625 Wham Dr
Room 141
Carbondale, IL 62901-4313 - Phone
- (618) 453-2361
- Fax
- (618) 453-6130
- NPI assigned
- Nov 17, 2015
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | 071008612 | IL | Primary |
Addresses
Primary practice location
625 Wham Dr
Room 141
Carbondale, IL 62901-4313
Mailing address
625 Wham Dr
Room 141
Carbondale, IL 62901-4313
Phone (618) 453-2361
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 071008612 | Other | IL | DEPT. OF FINANCIAL AND PROFESSIONAL REGULATION |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 071008612 | IL | MD | Clinical Psychologist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Southern Illinois University Carbondale Clinical Center | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Psychologist
- Carbondale, IL
- NPI 1174919351
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1447718400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1447718400000",
"number": "1891169629",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "625 WHAM DR",
"address_2": "ROOM 141",
"city": "CARBONDALE",
"state": "IL",
"postal_code": "629014313",
"telephone_number": "618-453-2361",
"fax_number": "618-453-6130"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "625 WHAM DR",
"address_2": "ROOM 141",
"city": "CARBONDALE",
"state": "IL",
"postal_code": "629014313",
"telephone_number": "618-453-2361",
"fax_number": "618-453-6130"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DRAKE",
"first_name": "CHAD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2015-11-17",
"last_updated": "2015-11-17",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "IL",
"license": "071008612",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "DEPT. OF FINANCIAL AND PROFESSIONAL REGULATION",
"identifier": "071008612",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Carbondale, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 17, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.