MEDICARE: PEAK PERFORMANCE NEUROFEEDBACK, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0850X	Adult Mental Health Clinic/Center	0810004027	VA
2	261QH0100X	Health Service Clinic/Center	0810004027	VA
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center	0810004027	VA

General Provider Information

NPI Number	:	1275913436
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEAK PERFORMANCE NEUROFEEDBACK, LLC

Provider Business Mailing Address
First Line	:	13800 COPPERMINE RD
Second Line	:	SUITE 183
City	:	HERNDON
State	:	VA
Zip	:	20171-6163
Country	:	US
Telephone Number	:	619-540-3235
Fax Number	:	703-234-2213

Provider Business Practice Location Address
First Line	:	13800 COPPERMINE RD
Second Line	:	SUITE 183
City	:	HERNDON
State	:	VA
Zip	:	20171-6163
Country	:	US
Telephone Number	:	619-540-3235
Fax Number	:	703-234-2213

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

Provider Enumeration Date	:	06/03/2015
Last Update Date	:	08/29/2016

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