Provider Demographics
NPI:1578963732
Name:INDIGO MENTAL HEALTH PLLC
Entity Type:Organization
Organization Name:INDIGO MENTAL HEALTH PLLC
Other - Org Name:INDIGO MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ISMAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GERENA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA, LMHCA, LMFTA
Authorized Official - Phone:425-591-2963
Mailing Address - Street 1:901 BOREN AVE
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-3595
Mailing Address - Country:US
Mailing Address - Phone:206-801-3555
Mailing Address - Fax:
Practice Address - Street 1:901 BOREN AVE
Practice Address - Street 2:SUITE 1300
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3595
Practice Address - Country:US
Practice Address - Phone:206-801-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA603393215261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)