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General NPI Number Information
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NPI Number | 1346015815
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Entity Type | Organization
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Legal Business Name | CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB
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Dates
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Enumeration Date | 11/15/2023
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Last Update Date | 11/15/2023
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Provider Practice Location Address
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Address Line | 4000 LEGATO RD STE 1100
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City | FAIRFAX
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State | VA
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Zip | 22033-2893
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Country | US
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Telephone | 571-336-2272
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Fax |
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Provider Business Mailing Address
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Address Line | 15000 POTOMAC TOWN PL STE 100-151
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City | WOODBRIDGE
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State | VA
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Zip | 22191-6586
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Country | US
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Telephone | 571-336-2272
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | TAWANA BUTLER
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Credential | LCSW
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Telephone | 817-913-5428
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TE1100X
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Taxonomy Name | Exercise & Sports Psychologist
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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