Provider Demographics
NPI:1598742140
Name:STAPLETON, KENNETH L (LP)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:STAPLETON
Suffix:
Gender:M
Credentials:LP
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 771
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-0771
Mailing Address - Country:US
Mailing Address - Phone:218-326-5694
Mailing Address - Fax:218-326-5313
Practice Address - Street 1:423 NE 4TH ST STE 2
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2968
Practice Address - Country:US
Practice Address - Phone:218-326-5694
Practice Address - Fax:218-326-5313
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-26
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3021103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN796713600Medicaid
MN1104205319OtherNPI2