Provider Demographics
NPI:1912965336
Name:DISPENZA, JOSEPH RICHARD (PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:RICHARD
Last Name:DISPENZA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 INLET COVE CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4214
Mailing Address - Country:US
Mailing Address - Phone:843-881-8805
Mailing Address - Fax:
Practice Address - Street 1:1092 JOHNNIE DODDS BLVD
Practice Address - Street 2:STE. 1A
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-6109
Practice Address - Country:US
Practice Address - Phone:843-881-8805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC539103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPSO189Medicaid