Provider Demographics
NPI:1255579140
Name:DEMICCO, LISA JANE
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:JANE
Last Name:DEMICCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 JUNIPER COURT
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10556-4123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 JUNIPER COURT
Practice Address - Street 2:
Practice Address - City:PEEKSKILL
Practice Address - State:NY
Practice Address - Zip Code:10556-4123
Practice Address - Country:US
Practice Address - Phone:914-736-7214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist