Provider Demographics
NPI:1336377126
Name:O'ROURKE, R. RYAN (LPC)
Entity type:Individual
Prefix:MS
First Name:R.
Middle Name:RYAN
Last Name:O'ROURKE
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 W FRANKLIN ST
Mailing Address - Street 2:NORTH END WELLNESS
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4028
Mailing Address - Country:US
Mailing Address - Phone:208-371-3671
Mailing Address - Fax:208-344-3059
Practice Address - Street 1:1502 W FRANKLIN ST
Practice Address - Street 2:NORTH END WELLNESS
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4028
Practice Address - Country:US
Practice Address - Phone:208-371-3671
Practice Address - Fax:208-344-3059
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC3651101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010162257OtherREGENTS BLUE SHIELD