Provider Demographics
NPI:1285399956
Name:DITTENHAUSER, JOANNA CLARK (MED, EDS, NCC, LPC-A)
Entity type:Individual
Prefix:MRS
First Name:JOANNA
Middle Name:CLARK
Last Name:DITTENHAUSER
Suffix:
Gender:F
Credentials:MED, EDS, NCC, LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 CALEDON CT
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-3132
Mailing Address - Country:US
Mailing Address - Phone:843-861-9871
Mailing Address - Fax:
Practice Address - Street 1:119 MANLY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601-3024
Practice Address - Country:US
Practice Address - Phone:864-534-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-07
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7834101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional