Provider Demographics
NPI:1780840892
Name:ROCKEY, MICKEY D
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:D
Last Name:ROCKEY
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:N3152 STATE ROAD 81
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WI
Mailing Address - Zip Code:53566-9397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N3152 STATE ROAD 81
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-9397
Practice Address - Country:US
Practice Address - Phone:608-328-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14814-131101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-6005699OtherEMPLOYER IDENTIFICATION NUMBER (EIN)