Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor | LPC-1240 | CO |
NPI | 1003067083 |
---|---|
Provider Name | Ms. Glenda Russell O'rourke |
First Address | Boulder, CO 80301 |
Second Address | Boulder, CO 80301 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/10/2008 |
Last Update Date | 08/10/2008 |