Elizabeth Randell Blackburn, LMFT
Individual provider Active NPI Marriage & Family Therapist · Poulsbo, WA
NPI 1104049568 · NPPES record last updated May 1, 2018
Key facts
- NPI
- 1104049568
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Marriage & Family Therapist 106H00000X
- License
- LF60554394 (WA)
- Practice address
- 20174 Front St NE
Poulsbo, WA 98370-7445 - Phone
- (404) 426-0486
- Fax
- (404) 426-0486
- NPI assigned
- Apr 11, 2007
- Sex
- Female
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MFT000939 | GA | MD | Marriage & Family Therapist |
| LF60554394 | WA | MD | Marriage & Family Therapist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Front Street Clinic Inc | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Marriage & Family Therapist | 106H00000X | LF60554394 | WA | Yes |
| Marriage & Family Therapist | 106H00000X | MFT000939 | GA |
Addresses
Primary practice location
20174 Front St NE
Poulsbo, WA 98370-7445
Mailing address
20174 Front St NE
Poulsbo, WA 98370-7445
Phone (404) 426-0486
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1104049568 | Other | GA | NPI |
| 125233048A | Medicaid | GA |
Other providers in Poulsbo, WA
- Birch Counseling
- Birch Hollow Therapy, PLLC
- Jennifer Lee Bird
- Sippara Metiku Birri
- Diane Marie Bishop
- Dale Bliss
- Kristin Switz Bloink
- Nina Bockholdt
- Kyle M Bogusz
- David Ryan Bolthouse
All providers in Poulsbo, WA · Marriage & Family Therapist in Washington
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 1, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.