Provider Demographics
NPI:1073297099
Name:INDIE LAINE LEARNING CO LLC
Entity type:Organization
Organization Name:INDIE LAINE LEARNING CO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF THERAPY & CONSULTATION
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:T
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, BCBA, LBA
Authorized Official - Phone:860-371-4586
Mailing Address - Street 1:7025 S 42ND AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-3508
Mailing Address - Country:US
Mailing Address - Phone:860-371-4586
Mailing Address - Fax:
Practice Address - Street 1:5210 N CENTRAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1489
Practice Address - Country:US
Practice Address - Phone:623-295-1109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-12
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty