Healthcare Provider Details

I. General information

NPI: 1902640907
Provider Name (Legal Business Name): SCOTT MUTCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 01/10/2025
Certification Date: 01/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 S OYSTER BAY RD
HICKSVILLE NY
11801-3511
US

IV. Provider business mailing address

950 S OYSTER BAY RD
HICKSVILLE NY
11801-3511
US

V. Phone/Fax

Practice location:
  • Phone: 516-822-6111
  • Fax:
Mailing address:
  • Phone: 516-822-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number126276-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: