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General NPI Number Information
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NPI Number | 1598120123
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Entity Type | Organization
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Legal Business Name | ECLECTIC DRAGONFLY THERAPY SERVICES, PLLC
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Dates
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Enumeration Date | 12/26/2015
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Last Update Date | 12/26/2015
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Provider Practice Location Address
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Address Line | 108 6TH AVE S
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City | PRINCETON
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State | MN
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Zip | 55371-1820
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Country | US
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Telephone | 763-482-1185
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 213
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City | PRINCETON
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State | MN
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Zip | 55371-0213
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Country | US
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Telephone | 763-482-1185
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Fax |
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Authorized Official
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Title or Position | OWNER/PSYCHOTHERAPIST
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Name | JACQUELINE KELLY-FADDLER
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Credential | LPCC
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Telephone | 763-482-1185
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 00842
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License Number State | MN
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