Healthcare Provider Details

I. General information

NPI: 1548043375
Provider Name (Legal Business Name): INDIGO MINDS ABA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4115 S SEMORAN BLVD APT 16
ORLANDO FL
32822-2427
US

IV. Provider business mailing address

4115 S SEMORAN BLVD APT 16
ORLANDO FL
32822-2427
US

V. Phone/Fax

Practice location:
  • Phone: 407-515-0189
  • Fax:
Mailing address:
  • Phone: 407-515-0189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: LUISA M PAREDES JIMENEZ
Title or Position: MGRM
Credential:
Phone: 407-515-0189