Healthcare Provider Details

I. General information

NPI: 1710548458
Provider Name (Legal Business Name): KATLYN MOONAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 08/06/2020
Certification Date: 08/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

632 N SHIAWASSEE ST
OWOSSO MI
48867-2232
US

IV. Provider business mailing address

PO BOX 289
MASON MI
48854-0289
US

V. Phone/Fax

Practice location:
  • Phone: 989-723-0330
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: