Organization
INDIE LAINE LEARNING CO LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JESSICA T COSTA M.S., BCBA, LBA (DIRECTOR OF THERAPY & CONSULTATION)
(860) 371-4586
Entity
Organization
Contact information
Practice address
5210 N CENTRAL AVE STE 101, PHOENIX, AZ 85012-1489
(623) 295-1109
Mailing address
7025 S 42ND AVE, PHOENIX, AZ 85041-3508
(860) 371-4586
Taxonomy
Speciality
Code
Description
License number
State
103K00000X
Behavior Analyst
—
—
225100000X
Physical Therapist
—
—
225X00000X
Occupational Therapist
—
—
235Z00000X
Speech-Language Pathologist
—
—
261QD1600X
Developmental Disabilities Clinic/Center
Primary
—
—
Other
Enumeration date
06/12/2023
Last updated
10/01/2024
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