=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003056698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENTIONAL HEARTS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2009
-----------------------------------------------------
Last Update Date | 02/23/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4200 NORTHSIDE PKWY NW BLDG 1, STE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30327-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-623-3331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4200 NORTHSIDE PKWY NW BLDG 1, STE 200
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30327-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-623-3331
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MICHAEL TODD WILSON
-----------------------------------------------------
Credential | LPC
-----------------------------------------------------
Telephone | 770-623-3331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | LPC004107
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------