Healthcare Provider Details

I. General information

NPI: 1275164543
Provider Name (Legal Business Name): EDWARD STABA PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

205 ARCHELLE DR
CARBONDALE IL
62901-1956
US

V. Phone/Fax

Practice location:
  • Phone: 618-997-5311
  • Fax:
Mailing address:
  • Phone: 561-602-8129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071.010207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: