MEDICARE: THE INDIGO CHILD THERAPEUTIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1386235323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE INDIGO CHILD THERAPEUTIC LLC

Provider Business Mailing Address
First Line	:	9722 GREEN APPLE TURN
Second Line	:
City	:	UPPER MARLBORO
State	:	MD
Zip	:	20772-4423
Country	:	US
Telephone Number	:	240-244-9778
Fax Number	:

Provider Business Practice Location Address
First Line	:	7491 OLD ALEXANDRIA FERRY RD
Second Line	:
City	:	CLINTON
State	:	MD
Zip	:	20735-1834
Country	:	US
Telephone Number	:	240-244-9778
Fax Number	:	240-269-7799

Authorized Official
Title or Position	:	OWNER
Name	:	MS. TIFFANY DICKS
Credential	:
Telephone Number	:	240-244-9778

Provider Enumeration Date	:	02/02/2021
Last Update Date	:	10/22/2024

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