| Revival Wellness & Ketamine | |
|
4200b Technology Ct Chantilly VA 20151-1214 | |
| (703) 988-3984 | |
| Not Available |
| Full Name | Revival Wellness & Ketamine |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 4200b Technology Ct, Chantilly, Virginia |
| Authorized Official Name and Position | Nicole Watson (FOUNDER) |
| Authorized Official Contact | 7039883984 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Revival Wellness & Ketamine 15406 Snowhill Ln Centreville VA 20120-1147 Ph: (703) 409-1572 | Revival Wellness & Ketamine 4200b Technology Ct Chantilly VA 20151-1214 Ph: (703) 988-3984 |
| NPI Number | 1093514655 |
|---|---|
| Provider Enumeration Date | 03/07/2025 |
| Last Update Date | 03/07/2025 |
| Certification Date | 03/07/2025 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1093514655 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
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