MEDICARE: DR. CARMINE UMBERTO IACONO PH.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	103TC1900X	Counseling Psychologist	22547	TX

General Provider Information

NPI Number	:	1740332394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARMINE UMBERTO IACONO PH.D.

Provider Business Mailing Address
First Line	:	1914 MORNING TIDE LN
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-6951
Country	:	US
Telephone Number	:	281-538-1385
Fax Number	:

Provider Business Practice Location Address
First Line	:	1914 MORNING TIDE LN
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-6951
Country	:	US
Telephone Number	:	281-538-1385
Fax Number	:

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	07/08/2007

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