Basic Information
| Provider Information | |||||||||
| NPI: | 1598013591 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESUPINSKI | ||||||||
| FirstName: | JOANNA | ||||||||
| MiddleName: | R | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4545 S 86TH ST | ||||||||
| Address2: | |||||||||
| City: | LINCOLN | ||||||||
| State: | NE | ||||||||
| PostalCode: | 685269227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4024836990 | ||||||||
| FaxNumber: | 4024837045 | ||||||||
| Practice Location | |||||||||
| Address1: | 10580 LIGON MILL RD STE 210 | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275876090 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192639592 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2012 | ||||||||
| LastUpdateDate: | 10/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103TC0700X | 4832 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1598013591 | 05 | NC | MEDICAID |