Basic Information
| Provider Information | |||||||||
| NPI: | 1629233655 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAAS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | E. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LSW CDCA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVANGELISTA | ||||||||
| OtherFirstName: | ELIZABETH | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 817 | ||||||||
| Address2: | 1521 N. DETROIT ST. | ||||||||
| City: | WEST LIBERTY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433570817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374658065 | ||||||||
| FaxNumber: | 9374650442 | ||||||||
| Practice Location | |||||||||
| Address1: | 131 N. MAIN ST. | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376421254 | ||||||||
| FaxNumber: | 9376422806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 12/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | I.1000277 | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YA0400X | 101076 | OH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | MC1705 | 05 | OH | MEDICAID |