Provider Demographics
NPI:1629481635
Name:O'ROURKE, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:O'ROURKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:KOENIGSKNECHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1507 WATERFORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-9630
Mailing Address - Country:US
Mailing Address - Phone:989-227-5404
Mailing Address - Fax:989-227-5415
Practice Address - Street 1:1507 WATERFORD PKWY
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879
Practice Address - Country:US
Practice Address - Phone:989-227-5404
Practice Address - Fax:989-227-5415
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501016792225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist