Provider Demographics
NPI:1225525199
Name:THOME-STAPLETON, SHANNON (LPC)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:THOME-STAPLETON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 SPRING PL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2072
Mailing Address - Country:US
Mailing Address - Phone:404-563-6600
Mailing Address - Fax:
Practice Address - Street 1:678 TOM BREWER RD
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4005
Practice Address - Country:US
Practice Address - Phone:770-554-3599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC010108101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA82-5177075Medicaid