Healthcare Provider Details

I. General information

NPI: 1497577209
Provider Name (Legal Business Name): BAILIE JADE STAAB PLADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 HEATHER RD
GERING NE
69341-1741
US

IV. Provider business mailing address

17 HEATHER RD
GERING NE
69341-1741
US

V. Phone/Fax

Practice location:
  • Phone: 308-641-3646
  • Fax:
Mailing address:
  • Phone: 308-641-3646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: