Provider Demographics
NPI:1902079734
Name:O'ROURKE, DIANE (MFT)
Entity type:Individual
Prefix:MRS
First Name:DIANE
Middle Name:
Last Name:O'ROURKE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 S SAN ANTONIO RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-3682
Mailing Address - Country:US
Mailing Address - Phone:209-521-2602
Mailing Address - Fax:
Practice Address - Street 1:4100 LAMARCK AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8907
Practice Address - Country:US
Practice Address - Phone:209-521-2602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-13
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 32808106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist