NPIMap

Organization Active NPI

Intown Pediatric Behavioral Wellness LLC

  • Clinical Child & Adolescent Psychologist
  • Atlanta, GA
National Provider Identifier
1265895569
Registry record updated Apr 4, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Child & Adolescent PsychologistTaxonomy code 103TC2200X
License
PSY003708 Issued in GA
Legal business name
INTOWN PEDIATRIC BEHAVIORAL WELLNESS LLC
Practice address
340 Boulevard NE
Suite 345
Atlanta, GA 30312-1273
Phone
(404) 653-0322
Fax
(404) 653-0466
NPI assigned
Apr 4, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 4, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jennifer Lynn Poulos, PSY.D.NPI 1063846509
Title
Owner/Pediatric Psychologist
Phone
(770) 656-1365

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Child & Adolescent PsychologistGroup: 193400000X SINGLE SPECIALTY GROUP 103TC2200X PSY003708 GA Primary

Addresses

Primary practice location

340 Boulevard NE
Suite 345
Atlanta, GA 30312-1273

Mailing address

1170 N Highland Ave NE
B10
Atlanta, GA 30306-3400
Phone (770) 656-1365

Other identifiers 1

IdentifierTypeStateIssuer
003139753AMedicaidGA

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1459728000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1459728000000",
    "number": "1265895569",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1170 N HIGHLAND AVE NE",
            "address_2": "B10",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303063400",
            "telephone_number": "770-656-1365",
            "fax_number": "404-653-0466"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "340 BOULEVARD NE",
            "address_2": "SUITE 345",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303121273",
            "telephone_number": "404-653-0322",
            "fax_number": "404-653-0466"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTOWN PEDIATRIC BEHAVIORAL WELLNESS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-04-04",
        "last_updated": "2016-04-04",
        "status": "A",
        "authorized_official_last_name": "POULOS",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "LYNN",
        "authorized_official_title_or_position": "OWNER/PEDIATRIC PSYCHOLOGIST",
        "authorized_official_telephone_number": "770-656-1365",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PSY.D."
    },
    "taxonomies": [
        {
            "code": "103TC2200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychologist, Clinical Child & Adolescent",
            "state": "GA",
            "license": "PSY003708",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "003139753A",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Atlanta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 4, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.