Provider Demographics
NPI:1174518781
Name:LIPPOLD, STEPHEN CRAIG (PHD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CRAIG
Last Name:LIPPOLD
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 W BAY AREA BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-2667
Mailing Address - Country:US
Mailing Address - Phone:281-218-8181
Mailing Address - Fax:281-218-7676
Practice Address - Street 1:1560 W BAY AREA BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-2667
Practice Address - Country:US
Practice Address - Phone:281-218-8181
Practice Address - Fax:281-218-7676
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23556103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6135241OtherUNITED HEALTH CARE
TX0004358643OtherAETNA
TX0004358643OtherAETNA
TX80057PMedicare ID - Type Unspecified