Provider Demographics
NPI:1720080872
Name:STAPLETON, CONSTANCE (PHD)
Entity type:Individual
Prefix:
First Name:CONSTANCE
Middle Name:
Last Name:STAPLETON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:CONSTANCE
Other - Middle Name:
Other - Last Name:LITTLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:211 PLEASANT HOME RD
Mailing Address - Street 2:BLDG G1
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-0518
Mailing Address - Country:US
Mailing Address - Phone:706-364-5228
Mailing Address - Fax:706-364-5229
Practice Address - Street 1:211 PLEASANT HOME RD
Practice Address - Street 2:BLDG G1
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-0518
Practice Address - Country:US
Practice Address - Phone:706-364-5228
Practice Address - Fax:706-364-5229
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2412103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAQ64034Medicare UPIN
GA68BBGRFMedicare PIN