Provider Demographics
NPI:1730623729
Name:A DRAGONFLY MIND, LLC
Entity type:Organization
Organization Name:A DRAGONFLY MIND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ZUMBAHLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-669-8378
Mailing Address - Street 1:2849 SW SPRING GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-3984
Mailing Address - Country:US
Mailing Address - Phone:217-369-1334
Mailing Address - Fax:888-977-2162
Practice Address - Street 1:10260 SW GREENBURG RD STE 400
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-5514
Practice Address - Country:US
Practice Address - Phone:773-669-8378
Practice Address - Fax:888-977-2162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-09
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA082604103G00000X
103G00000X
IL071009422103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty