Provider Demographics
NPI:1578276036
Name:ROUGHAN, MATTHEW DONALD (MS MFT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DONALD
Last Name:ROUGHAN
Suffix:
Gender:M
Credentials:MS MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1368 E 440 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-5127
Mailing Address - Country:US
Mailing Address - Phone:509-989-7869
Mailing Address - Fax:
Practice Address - Street 1:5314 RIVER RUN DR STE 350
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-7708
Practice Address - Country:US
Practice Address - Phone:817-787-9855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-29
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12941291-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist