NPIMap

Organization Active NPI

Baltimore Ketamine Clinic

  • Psychiatric/Mental Health Nurse Practitioner
  • Sparks Glencoe, MD
National Provider Identifier
1972145381
Registry record updated May 15, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatric/Mental Health Nurse PractitionerTaxonomy code 363LP0808X
Legal business name
BALTIMORE KETAMINE CLINIC
Practice address
909 Ridgebrook Rd Ste 202
Sparks Glencoe, MD 21152-9476
Phone
(410) 870-5482
Fax
(410) 628-1212
NPI assigned
Oct 17, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ivana Mitic, CRNANPI 1962743815
Title
Group Owner
Phone
(713) 412-3462

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Infusion Therapy Clinic/Center 261QI0500X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X Primary

Addresses

Primary practice location

909 Ridgebrook Rd Ste 202
Sparks Glencoe, MD 21152-9476

Mailing address

1 Texas Station CT Ste 320
Timonium, MD 21093-8290
Phone (410) 870-5482

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MD

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220624000152 MD Part B Supplier - Clinic/Group Practice 9739568569 Receives reassigned benefits from 4 practitioners
Practice locations: Sparks, MD

National Provider Directory

National Provider Directory
Tax ID family
Baltimore Ketamine Clinic2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1 Texas Station Ct
Ste 320
Timonium, MD 21093

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1571270400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747267200000",
    "number": "1972145381",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 TEXAS STATION CT STE 320",
            "city": "TIMONIUM",
            "state": "MD",
            "postal_code": "210938290",
            "telephone_number": "410-870-5482",
            "fax_number": "410-628-1212"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "909 RIDGEBROOK RD STE 202",
            "city": "SPARKS GLENCOE",
            "state": "MD",
            "postal_code": "211529476",
            "telephone_number": "410-870-5482",
            "fax_number": "410-628-1212"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BALTIMORE KETAMINE CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-10-17",
        "last_updated": "2025-05-15",
        "certification_date": "2025-05-15",
        "status": "A",
        "authorized_official_last_name": "MITIC",
        "authorized_official_first_name": "IVANA",
        "authorized_official_title_or_position": "GROUP OWNER",
        "authorized_official_telephone_number": "713-412-3462",
        "authorized_official_credential": "CRNA"
    },
    "taxonomies": [
        {
            "code": "261QI0500X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Infusion Therapy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Sparks Glencoe, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 15, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.