Provider Demographics
NPI:1689262891
Name:PRIVIA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:PRIVIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:AINSWORTH
Authorized Official - Last Name:IVESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-366-8831
Mailing Address - Street 1:950 N GLEBE RD STE 700
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-4173
Mailing Address - Country:US
Mailing Address - Phone:571-366-8831
Mailing Address - Fax:
Practice Address - Street 1:1201 SEVEN LOCKS RD STE 111
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-2957
Practice Address - Country:US
Practice Address - Phone:571-366-8850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty