1275382871 NPI number — SOUTH RIVER PSYCHIATRIC SERVICES, LLC

Table of content: (NPI 1275382871)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275382871 NPI number — SOUTH RIVER PSYCHIATRIC SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH RIVER PSYCHIATRIC SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275382871
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 KATHE CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21140-1312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-205-9205
Provider Business Mailing Address Fax Number:
619-268-5973

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 CRAIN HWY S STE 608
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN BURNIE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21061-6442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-205-9205
Provider Business Practice Location Address Fax Number:
619-268-5973
Provider Enumeration Date:
05/15/2024

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1720131295 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: D0086372 . This is a "STATE MEDICAL LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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