Provider Demographics
NPI:1205182177
Name:STAPLETON, SAMANTHA RAE
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:RAE
Last Name:STAPLETON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 E MAIN ST
Mailing Address - Street 2:SUITE16
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-2100
Mailing Address - Country:US
Mailing Address - Phone:740-286-5245
Mailing Address - Fax:740-286-7642
Practice Address - Street 1:731 E MAIN ST
Practice Address - Street 2:SUITE16
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-2100
Practice Address - Country:US
Practice Address - Phone:740-286-5245
Practice Address - Fax:740-286-7642
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0900850104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker