Healthcare Provider Details

I. General information

NPI: 1376394288
Provider Name (Legal Business Name): DRAGONFLY PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 WINDLEY DR
ST AUGUSTINE FL
32092-0124
US

IV. Provider business mailing address

920 WINDLEY DR
ST AUGUSTINE FL
32092-0124
US

V. Phone/Fax

Practice location:
  • Phone: 805-796-1797
  • Fax:
Mailing address:
  • Phone: 805-796-1797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH WIEDLUND-CALAM
Title or Position: OWNER
Credential:
Phone: 805-796-1797