Healthcare Provider Details

I. General information

NPI: 1902625569
Provider Name (Legal Business Name): INDIGO INTEGRATIVE PSYCHIATRY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

4030 WAKE FOREST RD
RALEIGH NC
27609-0010
US

IV. Provider business mailing address

4030 WAKE FOREST RD
RALEIGH NC
27609-0010
US

V. Phone/Fax

Practice location:
  • Phone: 828-419-4490
  • Fax:
Mailing address:
  • Phone: 828-419-4490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISTY STILLS
Title or Position: OWNER
Credential: PA-C
Phone: 828-419-4490