Provider Demographics
NPI:1790300937
Name:DIFONZO, TRACY ANN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANN
Last Name:DIFONZO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 SPRING LN
Mailing Address - Street 2:
Mailing Address - City:WYNDMOOR
Mailing Address - State:PA
Mailing Address - Zip Code:19038-8413
Mailing Address - Country:US
Mailing Address - Phone:610-420-4263
Mailing Address - Fax:
Practice Address - Street 1:504 SPRING LN
Practice Address - Street 2:
Practice Address - City:WYNDMOOR
Practice Address - State:PA
Practice Address - Zip Code:19038-8413
Practice Address - Country:US
Practice Address - Phone:610-420-4263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-13
Last Update Date:2020-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0156021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical