Provider Demographics
NPI:1093514655
Name:REVIVAL WELLNESS & KETAMINE
Entity type:Organization
Organization Name:REVIVAL WELLNESS & KETAMINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP, CRNA
Authorized Official - Phone:703-988-3984
Mailing Address - Street 1:15406 SNOWHILL LN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20120-1147
Mailing Address - Country:US
Mailing Address - Phone:703-409-1572
Mailing Address - Fax:
Practice Address - Street 1:4200B TECHNOLOGY CT
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1214
Practice Address - Country:US
Practice Address - Phone:703-988-3984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)