Provider Demographics
NPI:1790355618
Name:INTELLISTARS THERAPY
Entity Type:Organization
Organization Name:INTELLISTARS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-770-3658
Mailing Address - Street 1:13 SHENANDOAH DR
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4979
Mailing Address - Country:US
Mailing Address - Phone:248-770-3658
Mailing Address - Fax:
Practice Address - Street 1:3340 PEACHTREE RD NE STE 1800
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1064
Practice Address - Country:US
Practice Address - Phone:248-770-3658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-01
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0450671179OtherSTATE OF NJ