Provider Demographics
NPI:1164024279
Name:ROUGHTON, GINA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:ROUGHTON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6534 MCCARTY RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-9621
Mailing Address - Country:US
Mailing Address - Phone:989-798-3118
Mailing Address - Fax:
Practice Address - Street 1:2919 WILDER RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-9299
Practice Address - Country:US
Practice Address - Phone:989-671-5738
Practice Address - Fax:989-583-1900
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101008821235Z00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician