Provider Demographics
NPI:1124790415
Name:INDIGO ART THERAPY STUDIO LLC
Entity type:Organization
Organization Name:INDIGO ART THERAPY STUDIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ART THERAPIST, CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:DESOUSA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, ATR-BC
Authorized Official - Phone:904-520-4191
Mailing Address - Street 1:1804 SAN MARCO PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3247
Mailing Address - Country:US
Mailing Address - Phone:904-520-4191
Mailing Address - Fax:904-441-6901
Practice Address - Street 1:1804 SAN MARCO PL
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3247
Practice Address - Country:US
Practice Address - Phone:904-520-4191
Practice Address - Fax:904-441-6901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty