Provider Demographics
NPI:1033230818
Name:DRAGONFLY COUNSELING ASSOCIATES INC.
Entity type:Organization
Organization Name:DRAGONFLY COUNSELING ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:BREANNE
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:505-265-0753
Mailing Address - Street 1:1110 PENNSYLVANIA ST NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7404
Mailing Address - Country:US
Mailing Address - Phone:505-265-0753
Mailing Address - Fax:505-268-5722
Practice Address - Street 1:1110 PENNSYLVANIA ST NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7404
Practice Address - Country:US
Practice Address - Phone:505-265-0753
Practice Address - Fax:505-268-5722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-4453251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM65000862Medicaid
NMNM600178Medicaid