Provider Demographics
NPI:1285411744
Name:ROURK, STELLAR J
Entity type:Individual
Prefix:
First Name:STELLAR
Middle Name:J
Last Name:ROURK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYN
Other - Last Name:RUORK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DEADNAME
Mailing Address - Street 1:1333 7TH ST
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-1801
Mailing Address - Country:US
Mailing Address - Phone:707-228-3002
Mailing Address - Fax:
Practice Address - Street 1:201 ALAMEDA DEL PRADO STE 103
Practice Address - Street 2:
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94949-6698
Practice Address - Country:US
Practice Address - Phone:415-457-6964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health