Healthcare Provider Details

I. General information

NPI: 1396299442
Provider Name (Legal Business Name): LISA STAAB LCSW, LISW-CP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2016
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 JAMESTOWN DR UNIT 102
MURRELLS INLET SC
29576-7511
US

IV. Provider business mailing address

PO BOX 1492
MURRELLS INLET SC
29576-1492
US

V. Phone/Fax

Practice location:
  • Phone: 316-680-4794
  • Fax: 316-680-4794
Mailing address:
  • Phone: 316-680-4794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09924360
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11774
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801117714
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12048
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: