Provider Demographics
NPI:1063111680
Name:INDIGO THERAPY AND WELLNESS
Entity type:Organization
Organization Name:INDIGO THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:267-980-0878
Mailing Address - Street 1:525 BANCROFT RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1302
Mailing Address - Country:US
Mailing Address - Phone:267-980-0878
Mailing Address - Fax:
Practice Address - Street 1:525 BANCROFT RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1302
Practice Address - Country:US
Practice Address - Phone:267-980-0878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health