Provider Demographics
NPI:1831582295
Name:O ROURKE, TRICIA (CMT, LMT)
Entity type:Individual
Prefix:
First Name:TRICIA
Middle Name:
Last Name:O ROURKE
Suffix:
Gender:F
Credentials:CMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 W MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1481
Mailing Address - Country:US
Mailing Address - Phone:989-732-3626
Mailing Address - Fax:
Practice Address - Street 1:111 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1481
Practice Address - Country:US
Practice Address - Phone:989-732-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-10
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501002044225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist