Provider Demographics
NPI:1396299442
Name:STAAB, LISA (LCSW, LISW-CP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STAAB
Suffix:
Gender:F
Credentials:LCSW, LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1492
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-1492
Mailing Address - Country:US
Mailing Address - Phone:316-680-4794
Mailing Address - Fax:
Practice Address - Street 1:671 JAMESTOWN DR UNIT 102
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-7511
Practice Address - Country:US
Practice Address - Phone:316-680-4794
Practice Address - Fax:316-680-4794
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-06
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099243601041C0700X
SC117741041C0700X
MI68011177141041C0700X
WI120481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical