Healthcare Provider Details

I. General information

NPI: 1679421747
Provider Name (Legal Business Name): INDIGENA INTEGRATIVE WELLNESS A LICENSED CLINICAL SOCIAL WORKER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6049 DOUGLAS BLVD STE 20B
GRANITE BAY CA
95746-6275
US

IV. Provider business mailing address

12120 HERDAL DR
AUBURN CA
95603-5637
US

V. Phone/Fax

Practice location:
  • Phone: 408-460-5030
  • Fax:
Mailing address:
  • Phone: 408-460-5030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: REGINA FARIDNIA
Title or Position: CEO
Credential: LCSW, PHD, IMD
Phone: 408-460-5030