Provider Demographics
NPI:1235847286
Name:REVIVAL PSYCHIATRY AND KETAMINE CLINIC
Entity Type:Organization
Organization Name:REVIVAL PSYCHIATRY AND KETAMINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP/PMHNP
Authorized Official - Phone:480-613-8162
Mailing Address - Street 1:1220 S ALMA SCHOOL RD STE 212
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-2087
Mailing Address - Country:US
Mailing Address - Phone:480-613-8162
Mailing Address - Fax:480-900-8654
Practice Address - Street 1:1220 S ALMA SCHOOL RD STE 212
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-2087
Practice Address - Country:US
Practice Address - Phone:480-613-8162
Practice Address - Fax:480-900-8654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty