Basic Information
Provider Information | |||||||||
NPI: | 1689262891 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIVIA MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 950 N GLEBE RD STE 700 | ||||||||
Address2: |   | ||||||||
City: | ARLINGTON | ||||||||
State: | VA | ||||||||
PostalCode: | 222034173 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5713668831 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1201 SEVEN LOCKS RD STE 111 | ||||||||
Address2: |   | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208542957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5713668850 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2021 | ||||||||
LastUpdateDate: | 01/04/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | IVESS | ||||||||
AuthorizedOfficialFirstName: | COURTNEY | ||||||||
AuthorizedOfficialMiddleName: | AINSWORTH | ||||||||
AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 5713668831 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: | 01/04/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC1900X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Counseling | 103T00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |   |
No ID Information.