Healthcare Provider Details

I. General information

NPI: 1225447758
Provider Name (Legal Business Name): IVORY ELOISE O'ROURKE-KLEINKNECHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IVORY O'ROURKE PSYD

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 S STREAM BLVD STE 300
CHARLOTTE NC
28217-0143
US

IV. Provider business mailing address

4235 S STREAM BLVD STE 300
CHARLOTTE NC
28217-0143
US

V. Phone/Fax

Practice location:
  • Phone: 828-228-8970
  • Fax:
Mailing address:
  • Phone: 828-228-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6083
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: