Provider Demographics
NPI:1508965906
Name:DI FONZO, KARI LYNN (LCSW, CSAC)
Entity Type:Individual
Prefix:MS
First Name:KARI
Middle Name:LYNN
Last Name:DI FONZO
Suffix:
Gender:F
Credentials:LCSW, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 W BROWN DEER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BROWN DEER
Mailing Address - State:WI
Mailing Address - Zip Code:53209
Mailing Address - Country:US
Mailing Address - Phone:414-540-2170
Mailing Address - Fax:414-540-2171
Practice Address - Street 1:3900 W BROWN DEER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:BROWN DEER
Practice Address - State:WI
Practice Address - Zip Code:53209
Practice Address - Country:US
Practice Address - Phone:414-540-2170
Practice Address - Fax:414-540-2171
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7270123104100000X
WI72701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40963200Medicaid