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General NPI Number Information
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NPI Number | 1073496402
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Entity Type | Organization
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Legal Business Name | NY KETAMINE MEDICAL PRACTICE PLLC
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Dates
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Enumeration Date | 07/31/2025
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Last Update Date | 01/08/2026
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Provider Practice Location Address
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Address Line | 160 BROADWAY FL 16
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City | NEW YORK
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State | NY
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Zip | 10038-4207
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Country | US
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Telephone | 917-261-7370
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Fax | 917-477-6421
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Provider Business Mailing Address
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Address Line | PO BOX 32
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City | WOODLAWN
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State | TN
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Zip | 37191-0032
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Country | US
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Telephone | 917-261-7370
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Fax | 917-477-6421
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Authorized Official
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Title or Position | HEAD OF RCM
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Name | MARINA MAHONEY
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Credential |
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Telephone | 913-213-1084
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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