Provider Demographics
NPI:1083960140
Name:STAPLES, CAROLYN LORRAINE (LAC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:LORRAINE
Last Name:STAPLES
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1785 COUNTY ROAD 639 W
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-5101
Mailing Address - Country:US
Mailing Address - Phone:406-945-0426
Mailing Address - Fax:406-395-5643
Practice Address - Street 1:521 4TH ST
Practice Address - Street 2:
Practice Address - City:HAVRE
Practice Address - State:MT
Practice Address - Zip Code:59501-3649
Practice Address - Country:US
Practice Address - Phone:406-395-4305
Practice Address - Fax:406-395-5997
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1079101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)