Organization
SOUTH RIVER PSYCHIATRIC SERVICES, LLC
Active
Other names
South River Psychiatry
Organization subpart
No
Provider details
NPI number
Authorized official
DR. DONNA LORRAINE TICKNOR MD (OWNER/PHYSICIAN)
(410) 205-9205
Entity
Organization
Contact information
Practice address
1600 CRAIN HWY S STE 608, GLEN BURNIE, MD 21061-6442
(410) 205-9205
(619) 268-5973
Mailing address
408 KATHE CT, RIVA, MD 21140-1312
(410) 205-9205
(619) 268-5973
Taxonomy
Speciality
Code
Description
License number
State
2084P0800X
Psychiatry Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1720131295
INDIVIDUAL NPI
—
01
—
D0086372
STATE MEDICAL LICENSE
MD
Enumeration date
05/15/2024
Last updated
05/15/2024
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