Provider Demographics
NPI:1134261357
Name:ELLENBOGEN, TRACEY B (MSW,LCSW)
Entity type:Individual
Prefix:
First Name:TRACEY
Middle Name:B
Last Name:ELLENBOGEN
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 642
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-0642
Mailing Address - Country:US
Mailing Address - Phone:610-457-6361
Mailing Address - Fax:
Practice Address - Street 1:300 E LANCASTER AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-2139
Practice Address - Country:US
Practice Address - Phone:610-457-6361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0145071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical