Convergence Mental Performance and Preparation Lab

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

Legal business name

CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB

Doing business as

Convergence Mental Performance Lab
Convergence Prep

Practice address

4000 Legato Rd Ste 1100
Fairfax, VA 22033-2893

Phone

(571) 336-2272

NPI assigned

Nov 15, 2023

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Tawana Butler, LCSW

Title

Owner/Ceo

Phone

(817) 913-5428

Specialties & licenses 3

Addresses

Other names 2

• Convergence Mental Performance Lab Doing business as
• Convergence Prep Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Tawana Norman, LCSW

  • Clinical Social Worker
  • Fairfax, VA
  • NPI 1982391496
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1700006400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700006400000",
    "number": "1346015815",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "15000 POTOMAC TOWN PL STE 100-151",
            "city": "WOODBRIDGE",
            "state": "VA",
            "postal_code": "221916586",
            "telephone_number": "571-336-2272"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4000 LEGATO RD STE 1100",
            "city": "FAIRFAX",
            "state": "VA",
            "postal_code": "220332893",
            "telephone_number": "571-336-2272"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CONVERGENCE MENTAL PERFORMANCE AND PREPARATION LAB",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-11-15",
        "last_updated": "2023-11-15",
        "certification_date": "2023-11-15",
        "status": "A",
        "authorized_official_last_name": "BUTLER",
        "authorized_official_first_name": "TAWANA",
        "authorized_official_title_or_position": "OWNER/CEO",
        "authorized_official_telephone_number": "817-913-5428",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TE1100X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Exercise & Sports",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Convergence Mental Performance Lab",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Convergence Prep",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Maura Ann Constance, NP
• Emily Jean Constantino
• Yuko C Constas
• Consultant Corner LLC
• Laura Marie Continetti, DPT, CSCS
• Conversations Fairfax Counseling Center, LLC
• Julia Lynn Converse, LCSW
• Taejean Converti, DOM, MSOM, LAC
• Kerry L Conway Short, DPT, ATC
• Christine Shea Conway, PHD, LPC

• Clinical Social Worker in Fairfax, VA
• Providers in Fairfax, VA by specialty
• Clinical Social Worker in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 15, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.