Provider Demographics
NPI:1902550445
Name:CONVERGENT BRAIN DIAGNOSTICS
Entity Type:Organization
Organization Name:CONVERGENT BRAIN DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYJO
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS-MOTL
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:916-836-0036
Mailing Address - Street 1:4359 TOWN CENTER BLVD STE 217
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-7113
Mailing Address - Country:US
Mailing Address - Phone:916-836-0036
Mailing Address - Fax:916-345-7950
Practice Address - Street 1:4359 TOWN CENTER BLVD STE 217
Practice Address - Street 2:
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-7113
Practice Address - Country:US
Practice Address - Phone:916-836-0036
Practice Address - Fax:916-345-7950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty