Healthcare Provider Details

I. General information

NPI: 1386235323
Provider Name (Legal Business Name): THE INDIGO CHILD THERAPEUTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 10/22/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7491 OLD ALEXANDRIA FERRY RD
CLINTON MD
20735-1834
US

IV. Provider business mailing address

9722 GREEN APPLE TURN
UPPER MARLBORO MD
20772-4423
US

V. Phone/Fax

Practice location:
  • Phone: 240-244-9778
  • Fax: 240-269-7799
Mailing address:
  • Phone: 240-244-9778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MS. TIFFANY DICKS
Title or Position: OWNER
Credential:
Phone: 240-244-9778