Provider Demographics
NPI:1396296968
Name:FORTINO, MATTHEW G
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:G
Last Name:FORTINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9470
Mailing Address - Fax:239-343-9498
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 300
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-3831
Practice Address - Fax:239-343-9498
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY12541103TC0700X, 103T00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY931026892OtherUNITED HEALTHCARE
NY931026892OtherUNITED HEALTHCARE