Provider Demographics
NPI:1629233655
Name:STAAS, ELIZABETH E (LSW CDCA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:E
Last Name:STAAS
Suffix:
Gender:F
Credentials:LSW CDCA
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:EVANGELISTA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 817
Mailing Address - Street 2:1521 N. DETROIT ST.
Mailing Address - City:WEST LIBERTY
Mailing Address - State:OH
Mailing Address - Zip Code:43357-0817
Mailing Address - Country:US
Mailing Address - Phone:937-465-8065
Mailing Address - Fax:937-465-0442
Practice Address - Street 1:131 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040
Practice Address - Country:US
Practice Address - Phone:937-642-1254
Practice Address - Fax:937-642-2806
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.10002771041C0700X
OH101076101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMC1705Medicaid