| South River Psychiatry | |
|
1600 Crain Hwy S Ste 608 Glen Burnie MD 21061-6442 | |
| (410) 205-9205 | |
| (619) 268-5973 |
| Full Name | South River Psychiatry |
|---|---|
| Speciality | Psychiatry & Neurology - Psychiatry |
| Location | 1600 Crain Hwy S Ste 608, Glen Burnie, Maryland |
| Authorized Official Name and Position | Donna Lorraine Ticknor (OWNER/PHYSICIAN) |
| Authorized Official Contact | 4102059205 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| South River Psychiatry 408 Kathe Ct Riva MD 21140-1312 Ph: (410) 205-9205 | South River Psychiatry 1600 Crain Hwy S Ste 608 Glen Burnie MD 21061-6442 Ph: (410) 205-9205 |
| NPI Number | 1275382871 |
|---|---|
| Provider Enumeration Date | 05/15/2024 |
| Last Update Date | 05/15/2024 |
| Certification Date | 05/15/2024 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275382871 | NPI | - | NPPES |
| 1720131295 | Other | INDIVIDUAL NPI | |
| D0086372 | Other | MD | STATE MEDICAL LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
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