Provider Demographics
NPI:1487145462
Name:ROURKE, KELLY B (ASW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:ROURKE
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3517 CAMINO DEL RIO S STE 407
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4028
Mailing Address - Country:US
Mailing Address - Phone:619-955-8905
Mailing Address - Fax:
Practice Address - Street 1:3517 CAMINO DEL RIO S STE 407
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4028
Practice Address - Country:US
Practice Address - Phone:619-955-8905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA967461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI907812514400OtherTHE ALLIANCE FIRST HEALTH NETWORK