Provider Demographics
NPI:1295263762
Name:DRAGONFLY WELLNESS STUDIO LLC
Entity type:Organization
Organization Name:DRAGONFLY WELLNESS STUDIO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GAUDET
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-613-6843
Mailing Address - Street 1:84 GORDON FARMS RD
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2389
Mailing Address - Country:US
Mailing Address - Phone:207-613-6843
Mailing Address - Fax:207-613-6843
Practice Address - Street 1:84 GORDON FARMS RD
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-2389
Practice Address - Country:US
Practice Address - Phone:207-613-6843
Practice Address - Fax:207-419-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-30
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC141051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty