Provider Demographics
NPI:1598120123
Name:ECLECTIC DRAGONFLY THERAPY SERVICES, PLLC
Entity Type:Organization
Organization Name:ECLECTIC DRAGONFLY THERAPY SERVICES, PLLC
Other - Org Name:ECLECTIC DRAGONFLY THERAPY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY-FADDLER
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:763-482-1185
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-0213
Mailing Address - Country:US
Mailing Address - Phone:763-482-1185
Mailing Address - Fax:
Practice Address - Street 1:108 6TH AVE S
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1820
Practice Address - Country:US
Practice Address - Phone:763-482-1185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-26
Last Update Date:2015-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00842101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty