Healthcare Provider Details

I. General information

NPI: 1023983954
Provider Name (Legal Business Name): SCARLETT KATIE MOYNIHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2025
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 ROBINSON RD
CLINTON NY
13323-1418
US

IV. Provider business mailing address

9797 RIVER RD APT 7
MARCY NY
13403-2098
US

V. Phone/Fax

Practice location:
  • Phone: 315-853-6090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: