Provider Demographics
NPI:1063871218
Name:STALEY, NATHAN W (MA LPC)
Entity type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:W
Last Name:STALEY
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-3630
Mailing Address - Country:US
Mailing Address - Phone:816-607-1713
Mailing Address - Fax:
Practice Address - Street 1:819 MAIN ST
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MO
Practice Address - Zip Code:64152-3630
Practice Address - Country:US
Practice Address - Phone:816-607-1713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016001689101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional