Provider Demographics
NPI:1275382871
Name:SOUTH RIVER PSYCHIATRIC SERVICES, LLC
Entity type:Organization
Organization Name:SOUTH RIVER PSYCHIATRIC SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:TICKNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-205-9205
Mailing Address - Street 1:408 KATHE CT
Mailing Address - Street 2:
Mailing Address - City:RIVA
Mailing Address - State:MD
Mailing Address - Zip Code:21140-1312
Mailing Address - Country:US
Mailing Address - Phone:410-205-9205
Mailing Address - Fax:619-268-5973
Practice Address - Street 1:1600 CRAIN HWY S STE 608
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-6442
Practice Address - Country:US
Practice Address - Phone:410-205-9205
Practice Address - Fax:619-268-5973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1720131295OtherINDIVIDUAL NPI
MDD0086372OtherSTATE MEDICAL LICENSE