Healthcare Provider Details

I. General information

NPI: 1649118662
Provider Name (Legal Business Name): MACKENZIE ROURKE NCC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8306 JORDAN VALLEY WAY
FREDERICK MD
21702-5800
US

IV. Provider business mailing address

8306 JORDAN VALLEY WAY
FREDERICK MD
21702-5800
US

V. Phone/Fax

Practice location:
  • Phone: 757-239-5858
  • Fax:
Mailing address:
  • Phone: 757-239-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701015383
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: