Healthcare Provider Details

I. General information

NPI: 1043763972
Provider Name (Legal Business Name): INDIGO DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 75 BOX 1198
RUTHERON NM
87551-9725
US

IV. Provider business mailing address

HC 75 BOX 1198
RUTHERON NM
87551-9725
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-5315
  • Fax: 575-588-0199
Mailing address:
  • Phone: 505-699-5315
  • Fax: 575-588-0199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number350792
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number350792
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number350792
License Number StateNM
# 4
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number350792
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number350792
License Number StateNM
# 6
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number350792
License Number StateNM

VIII. Authorized Official

Name: MARIANA ULIBARRI HORAN
Title or Position: PSYCHO EDUCATIONAL DIAGNOSTICIAN
Credential: M.D. PH.D NCED
Phone: 505-699-5315