Organization
BALTIMORE KETAMINE CLINIC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
IVANA MITIC CRNA (GROUP OWNER)
(713) 412-3462
Entity
Organization
Contact information
Practice address
909 RIDGEBROOK RD STE 202, SPARKS GLENCOE, MD 21152-9476
(410) 870-5482
(410) 628-1212
Mailing address
1 TEXAS STATION CT STE 320, TIMONIUM, MD 21093-8290
(410) 870-5482
(410) 628-1212
Taxonomy
Speciality
Code
Description
License number
State
261QI0500X
Infusion Therapy Clinic/Center
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
—
—
Other
Enumeration date
10/17/2019
Last updated
05/15/2025
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