Provider Demographics
NPI:1134900087
Name:INDIGO GROVE COUNSELING LLC
Entity type:Organization
Organization Name:INDIGO GROVE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AUBREY
Authorized Official - Middle Name:
Authorized Official - Last Name:BASSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-336-0154
Mailing Address - Street 1:2717 MESILLA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3539
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2717 MESILLA ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3539
Practice Address - Country:US
Practice Address - Phone:505-336-0154
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)