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General NPI Number Information
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NPI Number | 1578963732
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Entity Type | Organization
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Legal Business Name | INDIGO MENTAL HEALTH PLLC
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Dates
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Enumeration Date | 08/25/2014
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Last Update Date | 08/25/2014
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Provider Practice Location Address
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Address Line | 901 BOREN AVE SUITE 1300
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City | SEATTLE
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State | WA
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Zip | 98104-3595
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Country | US
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Telephone | 206-801-3555
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Fax |
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Provider Business Mailing Address
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Address Line | 901 BOREN AVE SUITE 1300
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City | SEATTLE
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State | WA
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Zip | 98104-3595
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Country | US
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Telephone | 206-801-3555
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MR. ISMAEL E GERENA JR.
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Credential | MA., LMHCA, LMFTA
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Telephone | 425-591-2963
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | 603393215
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License Number State | WA
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