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Contact Information

CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB
4000 LEGATO RD STE 1100
FAIRFAX, VA22033-2893
 Phone: 571-336-2272
 Fax:
 Website:
 

Specialty

Taxonomy Code Specialty Code Provider Type

Clinical

1041C0700X 80 Licensed Clinical Social Worker
 

Exercise & Sports

103TE1100X 62 Psychologist, Clinical
 

Professional

101YP2500X
Indicates primary specialty

NPI Profile & details for CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB

NPI Number 1346015815
LBN Legal business name CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB
Authorized official TAWANA BUTLER - (OWNER/CEO)
Entity Organization
Organization subpart 1 No
Enumeration date 11/15/2023
Last updated 11/15/2023 - About 3 years ago
Identifiers n/a
1 Some organization health care providers are made up of components that furnish different types of health care or have separate physical locations where health care is furnished. These components and physical locations are not themselves legal entities, but are part of the organization health care provider (which is a legal entity). A covered organization provider may decide that its subparts (if it has any) should have their own NPI numbers. If a subpart conducts any HIPAA standard transactions on its own (e.g., separately from its parent), it must obtain its own NPI number.

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