Provider Demographics
NPI:1932184132
Name:MCDONNELL, JOSEPH DISTER (MS, LCDP)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:DISTER
Last Name:MCDONNELL
Suffix:
Gender:M
Credentials:MS, LCDP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 TERRACE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-4727
Mailing Address - Country:US
Mailing Address - Phone:401-829-2332
Mailing Address - Fax:
Practice Address - Street 1:162 TERRACE AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-4727
Practice Address - Country:US
Practice Address - Phone:401-829-2332
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILCDP00277101YA0400X
NE1601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health