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REVIVAL WELLNESS & KETAMINE
NPI 1093514655
Clinic/Center - Mental Health (Including Community Mental Health Center) in Chantilly, VA

Active since March 07, 2025CLIA 49D2269697 · Waiver
4200B TECHNOLOGY CT, CHANTILLY, VA 20151(703) 988-3984 Get Directions Write a Review

NPPES record last updated: November 3, 2025. Verified against the NPPES registry weekly; last sync: August 16, 2026.

Record update history: Nov 3, 2025, Mar 7, 2025 (2 updates tracked since 2025).

About Revival Wellness & Ketamine NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

REVIVAL WELLNESS & KETAMINE (NPI 1093514655) is a healthcare organization registered as a mental health (including community mental health center) in Chantilly, Virginia and active in the NPI registry since March 2025. The organization holds a CLIA Waiver certificate valid through September 29, 2026 and lists Nicole Watson, Founder, as its authorized official.

NPPES Registry Identity

NPI1093514655
Entity TypeOrganization
Primary Taxonomy261QM0801X
Legal Business NameREVIVAL WELLNESS & KETAMINE
Location Address4200B TECHNOLOGY CTChantilly, VA 20151-1214
Mailing Address4200b Technology CtChantilly, VA 20151-1214 · (703) 988-3984
Phone(703) 988-3984
Organization SubpartNo
Authorized OfficialNicole WatsonFounder · (703) 988-3984
Enumeration DateMarch 7, 2025
Last NPPES UpdateNovember 3, 20252 updates tracked since enumeration
NPPES CertifiedNovember 3, 2025
✔ NPI 1093514655 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyClinic/Center · Mental Health (Including Community Mental Health Center)Ambulatory Health Care Facilities
Taxonomy Code261QM0801X
4200B TECHNOLOGY CT, Chantilly, VA 20151
Open in Google Maps ↗

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 49D2269697

Revival Wellness And Ketamine · Chantilly, VA
Active · expires Sep 29, 2026
CLIA Number49D2269697
Laboratory TypeIV Therapy & Ketamine Inf
Certificate Effective DateSeptember 30, 2024
Certificate Expiration DateSeptember 29, 2026
Laboratory DirectorNicole Watson
Laboratory Phone(703) 988-3984
Laboratory LocationRevival Wellness And Ketamine4200-B Technology Court, Chantilly, VA 20151
CLIA data matches this NPI record on: Phone
This certificate is issued to a laboratory to perform only waived tests.

Other Providers at the Same Location NPPES 6

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

VIRTUAL PHYSIO, LLC
Physical Therapist
4200B TECHNOLOGY CT
CHANTILLY, VA 20151
Fairfax County (703) 828-0582
NICOLE LYNN WATSON CRNA
Nurse Practitioner (Psychiatric/Mental Health)
4200B TECHNOLOGY CT
CHANTILLY, VA 20151
Fairfax County (703) 988-3984
SUMMIT HEALTH PLLC
Clinic/Center (Primary Care)
4200B TECHNOLOGY CT
CHANTILLY, VA 20151
Fairfax County (571) 350-0929
MADELINE MARIE SEGALL DC, BS
Chiropractor
4200B TECHNOLOGY CT
CHANTILLY, VA 20151
Fairfax County (571) 482-4052
DR. EMILY DEROCCO D.C.
Chiropractor (Pediatric Chiropractor)
4200B TECHNOLOGY CT
CHANTILLY, VA 20151
Fairfax County (620) 504-2434
DR. SARAH A GILPATRICK CRNP
Nurse Practitioner (Family)
4200B TECHNOLOGY CT
CHANTILLY, VA 20151
Fairfax County (571) 350-0929

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Revival Wellness & Ketamine's NPI number?

The NPI number for Revival Wellness & Ketamine is 1093514655. It was assigned to this organization in the NPPES registry on March 7, 2025.

Where is Revival Wellness & Ketamine located?

Revival Wellness & Ketamine is located at 4200B Technology Ct, Chantilly, VA 20151. The listed phone number is (703) 988-3984.

What is Revival Wellness & Ketamine's specialty?

The primary specialty registered for this NPI is Clinic/Center, specializing in Mental Health (Including Community Mental Health Center), with taxonomy code 261QM0801X.

Does Revival Wellness & Ketamine hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 49D2269697) is associated with this NPI, valid through September 29, 2026. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Revival Wellness & Ketamine was last updated on November 3, 2025. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 9 months ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.