Healthcare Provider Details

I. General information

NPI: 1801970652
Provider Name (Legal Business Name): PATRICIA G ROURKE PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2092 S CUSTER RD
MONROE MI
48161-1831
US

IV. Provider business mailing address

7550 LUCERNE DR SUITE 405
MIDDLEBURG HEIGHTS OH
44130-6588
US

V. Phone/Fax

Practice location:
  • Phone: 734-242-8711
  • Fax: 734-242-3955
Mailing address:
  • Phone: 440-234-8833
  • Fax: 440-234-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301006139
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: