Healthcare Provider Details

I. General information

NPI: 1689200453
Provider Name (Legal Business Name): ELISE M STAAB LCPC, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2020
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 6TH ST
CLARKSTON WA
99403-2002
US

IV. Provider business mailing address

2654 27TH ST
CLARKSTON WA
99403-1698
US

V. Phone/Fax

Practice location:
  • Phone: 208-717-2288
  • Fax: 208-980-7055
Mailing address:
  • Phone: 509-295-1861
  • Fax: 208-980-7055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLCPC-8108
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-7627
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: