Provider Demographics
NPI:1851868202
Name:ROCKLAGE, MATTHEW (PMHNP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:ROCKLAGE
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 METRO PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9416
Mailing Address - Country:US
Mailing Address - Phone:239-236-8784
Mailing Address - Fax:
Practice Address - Street 1:4310 METRO PKWY STE 205
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9416
Practice Address - Country:US
Practice Address - Phone:833-362-7935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015165363LP0808X
FL11015556363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty