Healthcare Provider Details

I. General information

NPI: 1154565729
Provider Name (Legal Business Name): KEITH MCGOLDRICK PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 11/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1733 S 1100 E STE 102
SALT LAKE CITY UT
84105-3482
US

IV. Provider business mailing address

1733 S 1100 E STE 102
SALT LAKE CITY UT
84105-3482
US

V. Phone/Fax

Practice location:
  • Phone: 801-486-6632
  • Fax: 801-877-9995
Mailing address:
  • Phone: 801-486-6632
  • Fax: 801-877-9995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number9524802-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number9524802-2501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number9524802-2501
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9524802-2501
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number9524802-2501
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number9524802-2501
License Number StateUT
# 7
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number9524802-2501
License Number StateUT
# 8
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number9524802-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: