Basic Information
| Provider Information | |||||||||
| NPI: | 1306425863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAPLE | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 GLENRIDGE RD | ||||||||
| Address2: | |||||||||
| City: | GLENVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 123024528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853686900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 556 CLINTON AVE S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146201105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5854428422 | ||||||||
| FaxNumber: | 5854428494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2021 | ||||||||
| LastUpdateDate: | 08/30/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 01420800 | 05 | NY | MEDICAID |