Provider Demographics
NPI:1336749589
Name:STAYBACK, PAUL MICHAEL (LICSWA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:MICHAEL
Last Name:STAYBACK
Suffix:
Gender:M
Credentials:LICSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16668 132ND ST SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98290-6767
Mailing Address - Country:US
Mailing Address - Phone:201-696-1165
Mailing Address - Fax:
Practice Address - Street 1:16668 132ND ST SE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-6767
Practice Address - Country:US
Practice Address - Phone:201-696-1165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator