Healthcare Provider Details

I. General information

NPI: 1053457333
Provider Name (Legal Business Name): ELIZABETH NYBLADE PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 KEY ST SUITE 213
BELLINGHAM WA
98225-5232
US

IV. Provider business mailing address

1116 KEY ST SUITE 213
BELLINGHAM WA
98225-5232
US

V. Phone/Fax

Practice location:
  • Phone: 360-647-8295
  • Fax: 360-647-8296
Mailing address:
  • Phone: 360-647-8295
  • Fax: 360-647-8296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY0000035
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY0000035
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License NumberPY00000535
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPY00000535
License Number StateWA
# 5
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberPY00000535
License Number StateWA
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY00000535
License Number StateWA
# 7
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY00000535
License Number StateWA
# 8
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY00000535
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: