Healthcare Provider Details

I. General information

NPI: 1891379137
Provider Name (Legal Business Name): JOSEPHINE M DIFAZIO LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1477 S SCHODACK RD
CASTLETON NY
12033-9644
US

IV. Provider business mailing address

87 S LAKE AVE
ALBANY NY
12203-1108
US

V. Phone/Fax

Practice location:
  • Phone: 518-477-6072
  • Fax:
Mailing address:
  • Phone: 845-625-9087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number108906
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: