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General NPI Number Information
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NPI Number | 1841802816
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Entity Type | Organization
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Legal Business Name | SPORT PSYENCE, LLC
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Dates
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Enumeration Date | 08/20/2020
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Last Update Date | 08/20/2020
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Provider Practice Location Address
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Address Line | 5 S MONTAGUE ST
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City | ARLINGTON
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State | VA
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Zip | 22204-1007
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Country | US
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Telephone | 703-594-6585
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Fax |
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Provider Business Mailing Address
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Address Line | 5 S MONTAGUE ST
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City | ARLINGTON
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State | VA
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Zip | 22204-1007
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Country | US
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Telephone | 703-594-6585
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Fax |
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Authorized Official
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Title or Position | LICENSED PSYCHOLOGIST/CEO
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Name | DR. AMBER RONAI CARGILL
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Credential | PSY.D.
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Telephone | 703-594-6585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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