Provider Demographics
NPI:1154565729
Name:MCGOLDRICK, KEITH (PHD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:MCGOLDRICK
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 1:1733 S 1100 E STE 102
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3482
Mailing Address - Country:US
Mailing Address - Phone:801-486-6632
Mailing Address - Fax:801-877-9995
Practice Address - Street 1:1733 S 1100 E STE 102
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-3482
Practice Address - Country:US
Practice Address - Phone:801-486-6632
Practice Address - Fax:801-877-9995
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9524802-2501103T00000X, 103TA0700X, 103TB0200X, 103TC0700X, 103TF0200X, 103TH0100X, 103TM1800X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities