Provider Demographics
NPI:1780259226
Name:WOODSIDE, KEITH DELL
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:DELL
Last Name:WOODSIDE
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 1:15817 W MEADE LN
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9785
Mailing Address - Country:US
Mailing Address - Phone:480-717-2144
Mailing Address - Fax:
Practice Address - Street 1:15817 W MEADE LN
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-9785
Practice Address - Country:US
Practice Address - Phone:480-717-2144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist