Healthcare Provider Details

I. General information

NPI: 1275913436
Provider Name (Legal Business Name): PEAK PERFORMANCE NEUROFEEDBACK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 08/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 COPPERMINE RD SUITE 183
HERNDON VA
20171-6163
US

IV. Provider business mailing address

13800 COPPERMINE RD SUITE 183
HERNDON VA
20171-6163
US

V. Phone/Fax

Practice location:
  • Phone: 619-540-3235
  • Fax: 703-234-2213
Mailing address:
  • Phone: 619-540-3235
  • Fax: 703-234-2213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number0810004027
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number0810004027
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number0810004027
License Number StateVA

VIII. Authorized Official

Name: DR. BETH B DAVIS
Title or Position: PSYCHOLOGIST/CLINICAL DIRECTOR
Credential: PHD
Phone: 619-540-3235