Provider Demographics
NPI:1447620943
Name:DRAKE, MARTHA LOUISE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:LOUISE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 FORTINO BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2087
Mailing Address - Country:US
Mailing Address - Phone:719-305-8310
Mailing Address - Fax:719-305-9723
Practice Address - Street 1:704 FORTINO BLVD STE A
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2087
Practice Address - Country:US
Practice Address - Phone:719-305-8310
Practice Address - Fax:719-305-9723
Is Sole Proprietor?:No
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0000012235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist