Healthcare Provider Details

I. General information

NPI: 1821407503
Provider Name (Legal Business Name): INDIGO COUNSELING SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 LEXINGTON AVE STE 100
MANSFIELD OH
44907-2679
US

IV. Provider business mailing address

1230 LEXINGTON AVE STE 100
MANSFIELD OH
44907-2679
US

V. Phone/Fax

Practice location:
  • Phone: 419-775-1771
  • Fax: 419-775-1088
Mailing address:
  • Phone: 419-775-1771
  • Fax: 419-775-1088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberS1050
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4741
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number892648
License Number StateOH

VIII. Authorized Official

Name: GREGG RICHARDS
Title or Position: PRESIDENT
Credential: LPCC
Phone: 419-775-1771