Provider Demographics
NPI:1841802816
Name:SPORT PSYENCE, LLC
Entity Type:Organization
Organization Name:SPORT PSYENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:RONAI
Authorized Official - Last Name:CARGILL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:703-594-6585
Mailing Address - Street 1:5 S MONTAGUE ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1007
Mailing Address - Country:US
Mailing Address - Phone:703-594-6585
Mailing Address - Fax:
Practice Address - Street 1:5 S MONTAGUE ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1007
Practice Address - Country:US
Practice Address - Phone:703-594-6585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty