Organization
REVIVAL WELLNESS & KETAMINE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NICOLE WATSON PMHNP, CRNA (FOUNDER)
(703) 988-3984
Entity
Organization
Contact information
Practice address
4200B TECHNOLOGY CT, CHANTILLY, VA 20151-1214
(703) 988-3984
Mailing address
4200B TECHNOLOGY CT, CHANTILLY, VA 20151-1214
(703) 988-3984
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Enumeration date
03/07/2025
Last updated
11/03/2025
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