Provider Demographics
NPI:1346015815
Name:CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB
Entity Type:Organization
Organization Name:CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAWANA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:817-913-5428
Mailing Address - Street 1:15000 POTOMAC TOWN PL STE 100-151
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-6586
Mailing Address - Country:US
Mailing Address - Phone:571-336-2272
Mailing Address - Fax:
Practice Address - Street 1:4000 LEGATO RD STE 1100
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2893
Practice Address - Country:US
Practice Address - Phone:571-336-2272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-15
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty