Provider Demographics
NPI:1720792799
Name:REVITALIZE PSYCHIATRY, PLLC
Entity Type:Organization
Organization Name:REVITALIZE PSYCHIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:704-459-2181
Mailing Address - Street 1:8022 PROVIDENCE RD STE 500-229
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-9719
Mailing Address - Country:US
Mailing Address - Phone:704-459-2181
Mailing Address - Fax:704-533-9516
Practice Address - Street 1:11220 ELM LN STE 203-9
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0715
Practice Address - Country:US
Practice Address - Phone:704-459-2181
Practice Address - Fax:704-533-9516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)