MEDICARE: CONVERGENT BRAIN DIAGNOSTICS

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1902550445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONVERGENT BRAIN DIAGNOSTICS

Provider Business Mailing Address
First Line	:	4359 TOWN CENTER BLVD STE 217
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-7113
Country	:	US
Telephone Number	:	916-836-0036
Fax Number	:	916-345-7950

Provider Business Practice Location Address
First Line	:	4359 TOWN CENTER BLVD STE 217
Second Line	:
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-7113
Country	:	US
Telephone Number	:	916-836-0036
Fax Number	:	916-345-7950

Authorized Official
Title or Position	:	VICE PRESIDENT/CLINICAL DIRECTOR
Name	:	MRS. MARYJO BROOKS-MOTL
Credential	:	LMFT
Telephone Number	:	916-836-0036

Provider Enumeration Date	:	02/03/2022
Last Update Date	:	02/03/2022

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