Healthcare Provider Details

I. General information

NPI: 1073297099
Provider Name (Legal Business Name): INDIE LAINE LEARNING CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 10/01/2024
Certification Date: 10/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5210 N CENTRAL AVE STE 101
PHOENIX AZ
85012-1489
US

IV. Provider business mailing address

7025 S 42ND AVE
PHOENIX AZ
85041-3508
US

V. Phone/Fax

Practice location:
  • Phone: 623-295-1109
  • Fax:
Mailing address:
  • Phone: 860-371-4586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name: JESSICA T COSTA
Title or Position: DIRECTOR OF THERAPY & CONSULTATION
Credential: M.S., BCBA, LBA
Phone: 860-371-4586