Revival Wellness & Ketamine

Primary specialty

Mental Health Clinic/Center (Including Community Mental Health Center)Taxonomy code 261QM0801X

Legal business name

REVIVAL WELLNESS & KETAMINE

Practice address

4200B Technology CT
Chantilly, VA 20151-1214

Phone

(703) 988-3984

NPI assigned

Mar 7, 2025

Last updated

Nov 3, 2025By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Nicole Watson, PMHNP, CRNANPI 1063841971

Title

Founder

Phone

(703) 988-3984

Specialties & licenses 1

Addresses

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Nicole Lynn Watson, CRNA

  • Psychiatric/Mental Health Nurse Practitioner
  • Clifton, VA
  • NPI 1063841971
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1741305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1762128000000",
    "number": "1093514655",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4200B TECHNOLOGY CT",
            "city": "CHANTILLY",
            "state": "VA",
            "postal_code": "201511214",
            "telephone_number": "703-988-3984"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4200B TECHNOLOGY CT",
            "city": "CHANTILLY",
            "state": "VA",
            "postal_code": "201511214",
            "telephone_number": "703-988-3984"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVAL WELLNESS & KETAMINE",
        "organizational_subpart": "NO",
        "enumeration_date": "2025-03-07",
        "last_updated": "2025-11-03",
        "certification_date": "2025-11-03",
        "status": "A",
        "authorized_official_last_name": "WATSON",
        "authorized_official_first_name": "NICOLE",
        "authorized_official_title_or_position": "FOUNDER",
        "authorized_official_telephone_number": "703-988-3984",
        "authorized_official_credential": "PMHNP, CRNA"
    },
    "taxonomies": [
        {
            "code": "261QM0801X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Mental Health (Including Community Mental Health Center)",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Clinic/Center (Including Community Mental Health Center) in Chantilly, VA
• Providers in Chantilly, VA by specialty
• Mental Health Clinic/Center (Including Community Mental Health Center) in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 3, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.