Provider Demographics
NPI:1295830461
Name:ROURKE, MICHAEL J (LISW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:ROURKE
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 16667
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88004-6667
Mailing Address - Country:US
Mailing Address - Phone:505-644-8846
Mailing Address - Fax:505-522-5717
Practice Address - Street 1:3751 DEL REY BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-7710
Practice Address - Country:US
Practice Address - Phone:505-644-8846
Practice Address - Fax:505-522-5717
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-3206104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH-7732Medicaid