21D2146226 CLIA NUMBER - BALTIMORE KETAMINE CLINIC

Laboratory Demographics

  • CLIA Code: 21D2146226
  • Facility Name: BALTIMORE KETAMINE CLINIC
  • Facility Address: 909 RIDGEBROOK RD STE 202
    SPARKS, MD
    ZIP 21152
  • Facility Phone: 410 870-5482
  • Facility Type: Physician Office
  • Facility Type: Waiver
  • Lab Director: IVANA A. MITIC MSN CRNA
  • NPI Number: 1972145381
  • Taxonomy: 363LP0808X - Nurse Practitioner

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CLIA Record

Field Name Field Value
CLIA Number 21D2146226
LAB Type Physician Office
Facility Name BALTIMORE KETAMINE CLINIC
Street 909 RIDGEBROOK RD STE 202
City SPARKS
State MD
ZIP 21152
Phone 410 870-5482
Certificate Type Certificate of Waiver
Certificate Type Description This certificate is issued to a laboratory to perform only waived tests.
Certificate Effective Date 3/26/2024
Certificate Expiration Date 3/25/2026
Facility Type Physician Office
Lab Director IVANA A. MITIC MSN CRNA

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This page was last updated on: 9/29/2025