Revival Psychiatry and Ketamine Clinic

Primary specialty

Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X

Legal business name

REVIVAL PSYCHIATRY AND KETAMINE CLINIC

Practice address

1220 S Alma School Rd Ste 212
Mesa, AZ 85210-2087

Phone

(480) 613-8162

Fax

(480) 900-8654

NPI assigned

Nov 8, 2022

Organization subpart

No

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

Authorized official

Name

Erin Jones, FNP/PMHNP

Title

Owner/Provider

Phone

(480) 613-8162

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in AZ

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Ashleigh Michelle McDonnell, PMHNP-BC

  • Psychiatric/Mental Health Nurse Practitioner
  • Mesa, AZ
  • NPI 1023789963
  Medicare reassignment NPD
• Avery Dean Booth, PMHNP-BC

  • Psychiatric/Mental Health Nurse Practitioner
  • Mesa, AZ
  • NPI 1679371389
  NPD

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

{
    "created_epoch": "1667865600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1667865600000",
    "number": "1235847286",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1220 S ALMA SCHOOL RD STE 212",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852102087",
            "telephone_number": "480-613-8162",
            "fax_number": "480-900-8654"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1220 S ALMA SCHOOL RD STE 212",
            "city": "MESA",
            "state": "AZ",
            "postal_code": "852102087",
            "telephone_number": "480-613-8162",
            "fax_number": "480-900-8654"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "REVIVAL PSYCHIATRY AND KETAMINE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-11-08",
        "last_updated": "2022-11-08",
        "certification_date": "2022-11-08",
        "status": "A",
        "authorized_official_last_name": "JONES",
        "authorized_official_first_name": "ERIN",
        "authorized_official_title_or_position": "OWNER/PROVIDER",
        "authorized_official_telephone_number": "480-613-8162",
        "authorized_official_credential": "FNP/PMHNP"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "erin@revivalpsych.com",
            "affiliation": "N",
            "endpointDescription": "email",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "email",
            "address_1": "1220 S Alma School Rd Ste 212",
            "city": "Mesa",
            "state": "AZ",
            "country_code": "US",
            "postal_code": "852102087",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Jenessa Reyes Colocado
• April A Reyes

• Psychiatric/Mental Health Nurse Practitioner in Mesa, AZ
• Providers in Mesa, AZ by specialty
• Psychiatric/Mental Health Nurse Practitioner in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.