Provider Demographics
NPI:1174966915
Name:IDIC HEALTHCARE, PLLC
Entity type:Organization
Organization Name:IDIC HEALTHCARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOUSEWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:832-248-4636
Mailing Address - Street 1:5726 SAGAMORE BAY LN
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77469-7398
Mailing Address - Country:US
Mailing Address - Phone:832-248-4636
Mailing Address - Fax:866-804-7241
Practice Address - Street 1:627 W. 19TH ST.
Practice Address - Street 2:SUITE 203
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-3613
Practice Address - Country:US
Practice Address - Phone:832-248-4636
Practice Address - Fax:866-804-7241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX31626OtherLBSW LICENSE NUMBER
TX5210OtherLMFT LICENSE NUMBER