Healthcare Provider Details

I. General information

NPI: 1457632556
Provider Name (Legal Business Name): CATHERINE MARIE STAAB LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 BRYDEN AVE
LEWISTON ID
83501
US

IV. Provider business mailing address

PO BOX 1895
LEWISTON ID
83501
US

V. Phone/Fax

Practice location:
  • Phone: 208-798-1646
  • Fax: 208-798-5568
Mailing address:
  • Phone: 208-798-1646
  • Fax: 208-798-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-4613
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLCPC-5938
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: