Provider Demographics
NPI:1982721130
Name:STAAK HUBER, ELIZABETH JANE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JANE
Last Name:STAAK HUBER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:JANE
Other - Last Name:HUBER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:120 EAST AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5703
Mailing Address - Country:US
Mailing Address - Phone:203-750-9711
Mailing Address - Fax:203-750-9651
Practice Address - Street 1:120 EAST AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-5703
Practice Address - Country:US
Practice Address - Phone:203-750-9711
Practice Address - Fax:203-750-9651
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0054611041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008003511Medicaid
CT008003511Medicaid