Healthcare Provider Details

I. General information

NPI: 1164464814
Provider Name (Legal Business Name): R LITTLE ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 PROFESSIONAL PKWY SUITE C
AUGUSTA GA
30907-6521
US

IV. Provider business mailing address

2915 PROFESSIONAL PKWY SUITE C
AUGUSTA GA
30907-6521
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-5228
  • Fax: 706-364-5229
Mailing address:
  • Phone: 706-364-5228
  • Fax: 706-364-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2412
License Number StateGA

VIII. Authorized Official

Name: DR. CONNIE STAPLETON
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 706-364-5228