Active NPI
Dia Boutwell, PHD
- Clinical Psychologist
- Fayetteville, GA
National Provider Identifier
1740757731
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Clinical Psychologist
- License
- PSY004367
- Practice address
- 125 Howard LN Ste B
Fayetteville, GA 30215-1853 - Phone
- (502) 867-4851
- NPI assigned
- Oct 27, 2018
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinical Psychologist | 103TC0700X | PSY004367 | GA | Primary |
Addresses
Primary practice location
125 Howard LN Ste B
Fayetteville, GA 30215-1853
Mailing address
125 Howard LN Ste B
Fayetteville, GA 30215-1853
Phone (502) 867-4851
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PSY004367 | GA | MD | Clinical Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1540598400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1582243200000",
"number": "1740757731",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "125 HOWARD LN STE B",
"city": "FAYETTEVILLE",
"state": "GA",
"postal_code": "302151853",
"telephone_number": "502-867-4851"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "125 HOWARD LN STE B",
"city": "FAYETTEVILLE",
"state": "GA",
"postal_code": "302151853",
"telephone_number": "502-867-4851"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUTWELL",
"first_name": "DIA",
"credential": "PHD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2018-10-27",
"last_updated": "2020-02-21",
"certification_date": "2020-02-21",
"status": "A"
},
"taxonomies": [
{
"code": "103TC0700X",
"taxonomy_group": "",
"desc": "Psychologist, Clinical",
"state": "GA",
"license": "PSY004367",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fayetteville, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 21, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.