Healthcare Provider Details

I. General information

NPI: 1699249342
Provider Name (Legal Business Name): INDIGO COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 UNIVERSITY AVE W # 202
SAINT PAUL MN
55114-1769
US

IV. Provider business mailing address

2388 UNIVERSITY AVE W # 202
SAINT PAUL MN
55114-1769
US

V. Phone/Fax

Practice location:
  • Phone: 612-293-5124
  • Fax: 651-300-2702
Mailing address:
  • Phone: 612-293-5124
  • Fax: 651-300-2702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JOAN D HAUSE
Title or Position: LICENSED COUNSELOR
Credential: LPCC
Phone: 612-293-5128