Provider Demographics
NPI:1457084618
Name:DAMICO, STEPHEN
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:DAMICO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 FANNIN ST STE 1723
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2747
Mailing Address - Country:US
Mailing Address - Phone:631-790-7635
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST STE 1723
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2747
Practice Address - Country:US
Practice Address - Phone:631-790-7635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
TX120132235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist