Provider Demographics
NPI:1346612967
Name:DIFLAVIS, LANE (LCSW)
Entity Type:Individual
Prefix:
First Name:LANE
Middle Name:
Last Name:DIFLAVIS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 LOCUST ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5400
Mailing Address - Country:US
Mailing Address - Phone:215-985-4448
Mailing Address - Fax:215-732-1145
Practice Address - Street 1:1207 CHESTNUT ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-4131
Practice Address - Country:US
Practice Address - Phone:215-344-1155
Practice Address - Fax:215-732-1046
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103076186Medicaid