Organization
CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB
Active
Other names
Convergence Prep, Convergence Mental Performance Lab
Organization subpart
No
Provider details
NPI number
Authorized official
TAWANA BUTLER LCSW (OWNER/CEO)
(817) 913-5428
Entity
Organization
Contact information
Practice address
4000 LEGATO RD STE 1100, FAIRFAX, VA 22033-2893
(571) 336-2272
Mailing address
15000 POTOMAC TOWN PL STE 100-151, WOODBRIDGE, VA 22191-6586
(571) 336-2272
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
—
—
103TE1100X
Exercise & Sports Psychologist
—
—
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Enumeration date
11/15/2023
Last updated
11/15/2023
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