Provider Demographics
NPI:1013388966
Name:INDIGO WATERS COUNSELING SERVICES
Entity Type:Organization
Organization Name:INDIGO WATERS COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUTZMAN-LIVAK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:530-448-0203
Mailing Address - Street 1:PO BOX 2874
Mailing Address - Street 2:
Mailing Address - City:OLYMPIC VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:96146-2874
Mailing Address - Country:US
Mailing Address - Phone:530-448-0203
Mailing Address - Fax:
Practice Address - Street 1:13406 DONNER PASS RD
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-3822
Practice Address - Country:US
Practice Address - Phone:530-448-0203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA298931041C0700X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Multi-Specialty