Provider Demographics
NPI:1104205319
Name:STAPLETON PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:STAPLETON PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STAPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST (LP)
Authorized Official - Phone:218-326-5694
Mailing Address - Street 1:1749 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2576
Mailing Address - Country:US
Mailing Address - Phone:218-326-5694
Mailing Address - Fax:218-326-5313
Practice Address - Street 1:1749 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2576
Practice Address - Country:US
Practice Address - Phone:218-326-5694
Practice Address - Fax:218-326-5313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3021103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty