Provider Demographics
NPI:1609852854
Name:GOODHUE, ANGELIQUE D (MD)
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:D
Last Name:GOODHUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANGELIQUE
Other - Middle Name:
Other - Last Name:GOODHUE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1901 S BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7434 S STATE ST
Practice Address - Street 2:SOUTH VALLEY MENTAL HEALTH
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2014
Practice Address - Country:US
Practice Address - Phone:801-566-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9632536112052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107007839101OtherINTERMOUNTAIN HEALTHCARE
UT942938348G02OtherEDUCATORS MUTUAL
UT662594OtherDESERET MUTUAL
UT942938348OtherCHAMPUS
UTP00172497Medicare ID - Type UnspecifiedRAILROAD MEDICARE