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General NPI Number Information
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NPI Number | 1235847286
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Entity Type | Organization
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Legal Business Name | REVIVAL PSYCHIATRY AND KETAMINE CLINIC
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Dates
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Enumeration Date | 11/08/2022
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Last Update Date | 11/08/2022
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Provider Practice Location Address
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Address Line | 1220 S ALMA SCHOOL RD STE 212
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City | MESA
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State | AZ
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Zip | 85210-2087
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Country | US
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Telephone | 480-613-8162
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Fax | 480-900-8654
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Provider Business Mailing Address
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Address Line | 1220 S ALMA SCHOOL RD STE 212
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City | MESA
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State | AZ
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Zip | 85210-2087
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Country | US
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Telephone | 480-613-8162
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Fax | 480-900-8654
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Authorized Official
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Title or Position | OWNER/PROVIDER
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Name | ERIN JONES
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Credential | FNP/PMHNP
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Telephone | 480-613-8162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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