Healthcare Provider Details

I. General information

NPI: 1295263762
Provider Name (Legal Business Name): DRAGONFLY WELLNESS STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 GORDON FARMS RD
GORHAM ME
04038-2389
US

IV. Provider business mailing address

84 GORDON FARMS RD
GORHAM ME
04038-2389
US

V. Phone/Fax

Practice location:
  • Phone: 207-613-6843
  • Fax: 207-419-2732
Mailing address:
  • Phone: 207-613-6843
  • Fax: 207-613-6843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLC14105
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SUSAN ELIZABETH GAUDET
Title or Position: OWNER/FOUNDER
Credential: LCSW
Phone: 207-613-6843