Provider Demographics
NPI:1225447758
Name:O'ROURKE-KLEINKNECHT, IVORY ELOISE
Entity Type:Individual
Prefix:
First Name:IVORY
Middle Name:ELOISE
Last Name:O'ROURKE-KLEINKNECHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 STATE FARM RD STE 505
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4917
Mailing Address - Country:US
Mailing Address - Phone:828-268-7200
Mailing Address - Fax:
Practice Address - Street 1:895 STATE FARM RD STE 505
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4917
Practice Address - Country:US
Practice Address - Phone:828-268-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-08
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6083103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6758Medicaid
CA7420Medicaid
CA7068Medicaid