Provider Demographics
NPI:1861032492
Name:MARLA SAMUEL DBA DRAGONFLY TRANSFORMATIONAL ARTS LLC
Entity Type:Organization
Organization Name:MARLA SAMUEL DBA DRAGONFLY TRANSFORMATIONAL ARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:541-500-8655
Mailing Address - Street 1:PO BOX 1787
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-0261
Mailing Address - Country:US
Mailing Address - Phone:541-500-8655
Mailing Address - Fax:800-433-1396
Practice Address - Street 1:575 FAITH AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2508
Practice Address - Country:US
Practice Address - Phone:541-500-8655
Practice Address - Fax:800-433-1396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-11
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty