Provider Demographics
NPI:1124601125
Name:INDIGO BRIDGE COUNSELING, PLLC
Entity Type:Organization
Organization Name:INDIGO BRIDGE COUNSELING, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:A
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:918-891-6928
Mailing Address - Street 1:1541 E 61ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-0718
Mailing Address - Country:US
Mailing Address - Phone:918-891-6928
Mailing Address - Fax:
Practice Address - Street 1:1541 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-0718
Practice Address - Country:US
Practice Address - Phone:918-891-6928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK7580OtherLPC LICENSE