Provider Demographics
NPI:1366236697
Name:PRIVIA MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:PRIVIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNESSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-276-9254
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:800-973-1442
Mailing Address - Fax:
Practice Address - Street 1:16 GREENMEADOW DR STE 302
Practice Address - Street 2:
Practice Address - City:TIMONIUM
Practice Address - State:MD
Practice Address - Zip Code:21093-3200
Practice Address - Country:US
Practice Address - Phone:443-449-5604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty