Healthcare Provider Details

I. General information

NPI: 1851868202
Provider Name (Legal Business Name): MATTHEW ROCKLAGE PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

IV. Provider business mailing address

4310 METRO PKWY STE 205
FORT MYERS FL
33916-9416
US

V. Phone/Fax

Practice location:
  • Phone: 833-362-7935
  • Fax:
Mailing address:
  • Phone: 239-236-8784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95015165
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11015556
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: