Provider Demographics
NPI:1043763972
Name:INDIGO DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:INDIGO DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHO EDUCATIONAL DIAGNOSTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ULIBARRI HORAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD NCED
Authorized Official - Phone:505-699-5315
Mailing Address - Street 1:HC 75 BOX 1198
Mailing Address - Street 2:
Mailing Address - City:RUTHERON
Mailing Address - State:NM
Mailing Address - Zip Code:87551-9725
Mailing Address - Country:US
Mailing Address - Phone:505-699-5315
Mailing Address - Fax:575-588-0199
Practice Address - Street 1:HC 75 BOX 1198
Practice Address - Street 2:
Practice Address - City:RUTHERON
Practice Address - State:NM
Practice Address - Zip Code:87551-9725
Practice Address - Country:US
Practice Address - Phone:505-699-5315
Practice Address - Fax:575-588-0199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-27
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM350792103TB0200X, 103TM1800X, 251300000X, 251B00000X, 251C00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Single Specialty
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty