# BALTIMORE KETAMINE CLINIC

> Is this information incorrect? This page shows public data from NPPES. Update your record in NPPES and this page will update automatically within 7 days. [Update your NPPES record](https://nppes.cms.hhs.gov)

- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1972145381
- **Authorized official:** IVANA MITIC CRNA (GROUP OWNER)
- **Authorized official phone:** (713) 412-3462

## Contact information

- **Practice address:** 909 RIDGEBROOK RD STE 202, SPARKS GLENCOE, MD 21152-9476
- **Practice address phone:** (410) 870-5482
- **Practice address fax:** (410) 628-1212
- **Mailing address:** 1 TEXAS STATION CT STE 320, TIMONIUM, MD 21093-8290
- **Mailing address phone:** (410) 870-5482
- **Mailing address fax:** (410) 628-1212

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QI0500X | Infusion Therapy Clinic/Center | — | NULL | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | Yes |

## Other

- **Enumeration date:** 10/17/2019
- **Last updated:** 05/15/2025