Provider Demographics
NPI:1689200453
Name:STAAB, ELISE M (LCPC, LMHC)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:M
Last Name:STAAB
Suffix:
Gender:F
Credentials:LCPC, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2654 27TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1698
Mailing Address - Country:US
Mailing Address - Phone:509-295-1861
Mailing Address - Fax:208-980-7055
Practice Address - Street 1:827 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2002
Practice Address - Country:US
Practice Address - Phone:208-717-2288
Practice Address - Fax:208-980-7055
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-12
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-7627101YM0800X
IDLCPC-8108101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WALH61120561OtherLMHC
IDLCPC-8108OtherLCPC