Provider Demographics
NPI:1548733504
Name:GOODENOUGH, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:GOODENOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5353 N 16TH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3282
Mailing Address - Country:US
Mailing Address - Phone:602-826-0037
Mailing Address - Fax:
Practice Address - Street 1:5353 N 16TH ST STE 120
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3282
Practice Address - Country:US
Practice Address - Phone:607-423-5179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31093225100000X
WAPT60895437225100000X
NY043139225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist