Active NPI
Edward Staba, PSY.D
- Psychologist
- Marion, IL
National Provider Identifier
1275164543
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Psychologist
- License
- 071.010207
- Practice address
- 2401 W Main St
Marion, IL 62959-1188 - Phone
- (618) 997-5311
- NPI assigned
- Jan 27, 2020
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Psychologist | 103T00000X | 071.010207 | IL | Primary |
Addresses
Primary practice location
2401 W Main St
Marion, IL 62959-1188
Mailing address
205 Archelle Dr
Carbondale, IL 62901-1956
Phone (561) 602-8129
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 071.010207 | IL | MD | Psychologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1580083200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1580083200000",
"number": "1275164543",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "205 ARCHELLE DR",
"city": "CARBONDALE",
"state": "IL",
"postal_code": "629011956",
"telephone_number": "561-602-8129"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2401 W MAIN ST",
"city": "MARION",
"state": "IL",
"postal_code": "629591188",
"telephone_number": "618-997-5311"
}
],
"practiceLocations": [],
"basic": {
"last_name": "STABA",
"first_name": "EDWARD",
"name_prefix": "Dr.",
"credential": "PSY.D",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2020-01-27",
"last_updated": "2020-01-27",
"certification_date": "2020-01-27",
"status": "A"
},
"taxonomies": [
{
"code": "103T00000X",
"taxonomy_group": "",
"desc": "Psychologist",
"state": "IL",
"license": "071.010207",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Marion, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 27, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.