Healthcare Provider Details

I. General information

NPI: 1093542862
Provider Name (Legal Business Name): INDIGO COUNSELING PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 NW 5TH ST
BRAINERD MN
56401-2904
US

IV. Provider business mailing address

6736 OJIBWA RD
BRAINERD MN
56401-7034
US

V. Phone/Fax

Practice location:
  • Phone: 218-232-3089
  • Fax: 218-302-0440
Mailing address:
  • Phone: 218-232-3089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KARLA VAN WIENEN
Title or Position: CREDENTIALING / CONTRACTING
Credential:
Phone: 320-746-0025