Healthcare Provider Details

I. General information

NPI: 1013388966
Provider Name (Legal Business Name): INDIGO WATERS COUNSELING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2015
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13406 DONNER PASS RD
TRUCKEE CA
96161-3822
US

IV. Provider business mailing address

PO BOX 2874
OLYMPIC VALLEY CA
96146-2874
US

V. Phone/Fax

Practice location:
  • Phone: 530-448-0203
  • Fax:
Mailing address:
  • Phone: 530-448-0203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number29893
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number29893
License Number StateCA

VIII. Authorized Official

Name: MRS. KIRSTEN BRUTZMAN-LIVAK
Title or Position: OWNER
Credential: L.C.S.W.
Phone: 530-448-0203