Healthcare Provider Details

I. General information

NPI: 1972145381
Provider Name (Legal Business Name): BALTIMORE KETAMINE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2019
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 RIDGEBROOK RD STE 202
SPARKS GLENCOE MD
21152-9476
US

IV. Provider business mailing address

1 TEXAS STATION CT STE 320
TIMONIUM MD
21093-8290
US

V. Phone/Fax

Practice location:
  • Phone: 410-870-5482
  • Fax: 410-628-1212
Mailing address:
  • Phone: 410-870-5482
  • Fax: 410-628-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IVANA MITIC
Title or Position: GROUP OWNER
Credential: CRNA
Phone: 713-412-3462