Healthcare Provider Details

I. General information

NPI: 1184493793
Provider Name (Legal Business Name): MATT RAY GAUGER LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2023
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 3RD AVE NW
WATERTOWN SD
57201-2311
US

IV. Provider business mailing address

120 3RD AVE NW
WATERTOWN SD
57201-2311
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-5262
  • Fax: 605-886-5228
Mailing address:
  • Phone: 605-886-5262
  • Fax: 605-886-5228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1729303
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: