Provider Demographics
NPI:1669732046
Name:DECICCO, DEVAN MEADE (MA, CCC-SLP)
Entity type:Individual
Prefix:MR
First Name:DEVAN
Middle Name:MEADE
Last Name:DECICCO
Suffix:
Gender:M
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 BUGBEE DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4204
Mailing Address - Country:US
Mailing Address - Phone:315-956-9773
Mailing Address - Fax:
Practice Address - Street 1:1351 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4531
Practice Address - Country:US
Practice Address - Phone:315-785-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-21
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021925-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist