Basic Information
| Provider Information | |||||||||
| NPI: | 1760071542 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAAB | ||||||||
| FirstName: | KEELIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PLPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VALENTI | ||||||||
| OtherFirstName: | KEELIN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 227 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FESTUS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630281952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369312700 | ||||||||
| FaxNumber: | 6369315304 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SENN THOMAS DR | ||||||||
| Address2: | |||||||||
| City: | HERCULANEUM | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630481033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6369312700 | ||||||||
| FaxNumber: | 6369315304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2021 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YP2500X | 2021014949 | MO | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.