Provider Demographics
NPI:1851788897
Name:GODECKE, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GODECKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S CHIPETA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1222
Mailing Address - Country:US
Mailing Address - Phone:406-925-2712
Mailing Address - Fax:
Practice Address - Street 1:501 S CHIPETA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1222
Practice Address - Country:US
Practice Address - Phone:406-925-2712
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10093895-89052084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program