Healthcare Provider Details

I. General information

NPI: 1720080872
Provider Name (Legal Business Name): CONSTANCE STAPLETON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CONSTANCE LITTLE PHD

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 07/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 PLEASANT HOME RD BLDG G1
AUGUSTA GA
30907-0518
US

IV. Provider business mailing address

211 PLEASANT HOME RD BLDG G1
AUGUSTA GA
30907-0518
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:
Title or Position:
Credential:
Phone: