Provider Demographics
NPI:1851134746
Name:PROFOUND PERFORMANCE LLC
Entity type:Organization
Organization Name:PROFOUND PERFORMANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMEAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:434-429-0024
Mailing Address - Street 1:641 UPPER ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1031
Mailing Address - Country:US
Mailing Address - Phone:434-288-7805
Mailing Address - Fax:
Practice Address - Street 1:641 UPPER ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1031
Practice Address - Country:US
Practice Address - Phone:434-288-7805
Practice Address - Fax:434-228-7813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health