NPIMap

Organization Active NPI

South River Psychiatric Services, LLC

Doing business as South River Psychiatry

  • Psychiatry Physician
  • Glen Burnie, MD
National Provider Identifier
1275382871
Registry record updated May 15, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
SOUTH RIVER PSYCHIATRIC SERVICES, LLC
Doing business as
South River Psychiatry
Practice address
1600 Crain Hwy S Ste 608
Glen Burnie, MD 21061-6442
Phone
(410) 205-9205
Fax
(619) 268-5973
NPI assigned
May 15, 2024
Last updated
May 15, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 15, 2024

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

Authorized official

Name
Dr. Donna Lorraine Ticknor, MDNPI 1720131295
Title
Owner/Physician
Phone
(410) 205-9205

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 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2084P0800X Primary

Addresses

Primary practice location

1600 Crain Hwy S Ste 608
Glen Burnie, MD 21061-6442

Mailing address

408 Kathe CT
Riva, MD 21140-1312
Phone (410) 205-9205

Other identifiers 2

IdentifierTypeStateIssuer
1720131295OtherINDIVIDUAL NPI
D0086372OtherMDSTATE MEDICAL LICENSE

Other names 1

  • South River Psychiatry Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1715731200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1715731200000",
    "number": "1275382871",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "408 KATHE CT",
            "city": "RIVA",
            "state": "MD",
            "postal_code": "211401312",
            "telephone_number": "410-205-9205",
            "fax_number": "619-268-5973"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 CRAIN HWY S STE 608",
            "city": "GLEN BURNIE",
            "state": "MD",
            "postal_code": "210616442",
            "telephone_number": "410-205-9205",
            "fax_number": "619-268-5973"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTH RIVER PSYCHIATRIC SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-05-15",
        "last_updated": "2024-05-15",
        "certification_date": "2024-05-15",
        "status": "A",
        "authorized_official_last_name": "TICKNOR",
        "authorized_official_first_name": "DONNA",
        "authorized_official_middle_name": "LORRAINE",
        "authorized_official_title_or_position": "OWNER/PHYSICIAN",
        "authorized_official_telephone_number": "410-205-9205",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDIVIDUAL NPI",
            "identifier": "1720131295",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "STATE MEDICAL LICENSE",
            "identifier": "D0086372",
            "state": "MD"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "South River Psychiatry",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Glen Burnie, MD

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 15, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.