Healthcare Provider Details

I. General information

NPI: 1790745248
Provider Name (Legal Business Name): SAM GOLDSTEIN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S 500 E SUITE 100
SLC UT
84102-2015
US

IV. Provider business mailing address

230 S 500 E SUITE 100
SLC UT
84102-2015
US

V. Phone/Fax

Practice location:
  • Phone: 801-532-1484
  • Fax: 801-532-1486
Mailing address:
  • Phone: 801-532-1484
  • Fax: 801-532-1486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number110924-2501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number110924-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: