Provider Demographics
NPI:1972261824
Name:KETAMINE PSYCHOLYTIC THERAPY LLC
Entity Type:Organization
Organization Name:KETAMINE PSYCHOLYTIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-730-9097
Mailing Address - Street 1:45 CASTLE ROCK ROAD STE 2A
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86351
Mailing Address - Country:US
Mailing Address - Phone:610-730-9097
Mailing Address - Fax:
Practice Address - Street 1:45 CASTLE ROCK ROAD STE 2A
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86351
Practice Address - Country:US
Practice Address - Phone:928-814-5269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-07
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service