Provider Demographics
NPI:1922553056
Name:INDIGO KIDS BEHAVIORAL LEARNING LLC
Entity Type:Organization
Organization Name:INDIGO KIDS BEHAVIORAL LEARNING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:321-890-4038
Mailing Address - Street 1:992 TILLERY WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9163
Mailing Address - Country:US
Mailing Address - Phone:321-890-4038
Mailing Address - Fax:
Practice Address - Street 1:992 TILLERY WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-9163
Practice Address - Country:US
Practice Address - Phone:321-890-4038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-16-22688251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health