Provider Demographics
NPI:1598013591
Name:DESUPINSKI, JOANNA R
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:R
Last Name:DESUPINSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4545 S 86TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-9227
Mailing Address - Country:US
Mailing Address - Phone:402-483-6990
Mailing Address - Fax:402-483-7045
Practice Address - Street 1:10580 LIGON MILL RD STE 210
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6090
Practice Address - Country:US
Practice Address - Phone:919-263-9592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-22
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC4832103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1598013591Medicaid