=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790674646
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DRAGONFLY KIDS THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2025
-----------------------------------------------------
Last Update Date | 07/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7631 PONDEROSA PNE
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78015-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-203-0904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7631 PONDEROSA PNE
-----------------------------------------------------
City | BOERNE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78015-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-203-0904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | AVERY DE LA PENA
-----------------------------------------------------
Credential | OTR
-----------------------------------------------------
Telephone | 830-203-0904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------