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General NPI Number Information
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NPI Number | 1386235323
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Entity Type | Organization
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Legal Business Name | THE INDIGO CHILD THERAPEUTIC LLC
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Dates
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Enumeration Date | 02/02/2021
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Last Update Date | 10/22/2024
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Provider Practice Location Address
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Address Line | 7491 OLD ALEXANDRIA FERRY RD
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City | CLINTON
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State | MD
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Zip | 20735-1834
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Country | US
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Telephone | 240-244-9778
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Fax | 240-269-7799
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Provider Business Mailing Address
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Address Line | 9722 GREEN APPLE TURN
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City | UPPER MARLBORO
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State | MD
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Zip | 20772-4423
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Country | US
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Telephone | 240-244-9778
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. TIFFANY DICKS
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Credential |
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Telephone | 240-244-9778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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