Provider Demographics
NPI:1508750506
Name:STAPLETON, SHUNTRICE
Entity type:Individual
Prefix:
First Name:SHUNTRICE
Middle Name:
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:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:WRENS
Mailing Address - State:GA
Mailing Address - Zip Code:30833-0193
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2003 STOREY MILL ESTATE DR
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-7807
Practice Address - Country:US
Practice Address - Phone:706-578-4367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-04
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANA101YM0800X
GA1813019101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health