Provider Demographics
NPI:1598428765
Name:KIMMEL, INDIGO (BT)
Entity type:Individual
Prefix:
First Name:INDIGO
Middle Name:
Last Name:KIMMEL
Suffix:
Gender:F
Credentials:BT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 FRONT ST S UNIT C108
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-4233
Mailing Address - Country:US
Mailing Address - Phone:206-259-1157
Mailing Address - Fax:
Practice Address - Street 1:1375 NW MALL ST STE 4
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-8950
Practice Address - Country:US
Practice Address - Phone:425-654-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician