Provider Demographics
NPI:1184053589
Name:STAPLES, KAITLIN
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:STAPLES
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 1:7058 GERMANTOWN AVENUE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119
Mailing Address - Country:US
Mailing Address - Phone:215-821-7211
Mailing Address - Fax:
Practice Address - Street 1:7058 GERMANTOWN AVENUE
Practice Address - Street 2:SUITE 204
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119
Practice Address - Country:US
Practice Address - Phone:215-821-7211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-06
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
PAPC008772101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)