MEDICARE: DR. ELISABETH ANNE MOUGHTY PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0700X	Adult Development & Aging Psychologist	017936-1	NY
2	103TP2701X	Group Psychotherapy Psychologist	017936-1	NY
3	103TH0004X	Health Psychologist	017936-1	NY
4	103T00000X	Psychologist	017936-1	NY

General Provider Information

NPI Number	:	1851535439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISABETH ANNE MOUGHTY PSY.D.

Provider Business Mailing Address
First Line	:	7000 E GENESEE ST BLDG B
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1131
Country	:	US
Telephone Number	:	315-391-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	7000 E GENESEE ST BLDG B
Second Line	:
City	:	FAYETTEVILLE
State	:	NY
Zip	:	13066-1131
Country	:	US
Telephone Number	:	315-391-8500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2009
Last Update Date	:	04/09/2026

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