Provider Demographics
NPI:1831279389
Name:O'ROURKE, CHARLES (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:O'ROURKE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MONUMENT SQ STE 401
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4771
Mailing Address - Country:US
Mailing Address - Phone:207-274-1663
Mailing Address - Fax:
Practice Address - Street 1:22 MONUMENT SQ STE 401
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4771
Practice Address - Country:US
Practice Address - Phone:207-274-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC115111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432135199Medicaid