Provider Demographics
NPI:1124178090
Name:ROUGHTON, KENNETH R (PHD)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:R
Last Name:ROUGHTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 E RACE ST
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:WA
Mailing Address - Zip Code:99328-1646
Mailing Address - Country:US
Mailing Address - Phone:509-382-1383
Mailing Address - Fax:509-382-1166
Practice Address - Street 1:221 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:WA
Practice Address - Zip Code:99328-1317
Practice Address - Country:US
Practice Address - Phone:509-382-1164
Practice Address - Fax:509-382-1166
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002083103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8809081Medicare PIN