Healthcare Provider Details

I. General information

NPI: 1790355618
Provider Name (Legal Business Name): INTELLISTARS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 UPPER RIVERDALE RD STE D
RIVERDALE GA
30274-2556
US

IV. Provider business mailing address

13 SHENANDOAH DR
LAKEWOOD NJ
08701-4979
US

V. Phone/Fax

Practice location:
  • Phone: 248-770-3658
  • Fax:
Mailing address:
  • Phone: 248-770-3658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MIRIAM GREENWALD
Title or Position: DIRECTOR
Credential:
Phone: 248-770-3658