Provider Demographics
NPI:1801970652
Name:ROURKE, PATRICIA G (PHD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:G
Last Name:ROURKE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7550 LUCERNE DR
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-6588
Mailing Address - Country:US
Mailing Address - Phone:440-234-8833
Mailing Address - Fax:440-234-3313
Practice Address - Street 1:2092 S CUSTER RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1831
Practice Address - Country:US
Practice Address - Phone:734-242-8711
Practice Address - Fax:734-242-3955
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI$$$$$$$$$Medicaid
MIP38320002Medicare PIN