Provider Demographics
NPI:1285025205
Name:STAAB, STEVEN (MC)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:STAAB
Suffix:
Gender:M
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 14
Mailing Address - Street 2:
Mailing Address - City:BASIN
Mailing Address - State:WY
Mailing Address - Zip Code:82410-0014
Mailing Address - Country:US
Mailing Address - Phone:307-431-2869
Mailing Address - Fax:307-440-2504
Practice Address - Street 1:409 S 9TH ST
Practice Address - Street 2:
Practice Address - City:BASIN
Practice Address - State:WY
Practice Address - Zip Code:82410-0014
Practice Address - Country:US
Practice Address - Phone:307-431-2869
Practice Address - Fax:307-440-2504
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYLPC-528101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional