Healthcare Provider Details

I. General information

NPI: 1841802816
Provider Name (Legal Business Name): SPORT PSYENCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 S MONTAGUE ST
ARLINGTON VA
22204-1007
US

IV. Provider business mailing address

5 S MONTAGUE ST
ARLINGTON VA
22204-1007
US

V. Phone/Fax

Practice location:
  • Phone: 703-594-6585
  • Fax:
Mailing address:
  • Phone: 703-594-6585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. AMBER RONAI CARGILL
Title or Position: LICENSED PSYCHOLOGIST/CEO
Credential: PSY.D.
Phone: 703-594-6585