=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104049568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH RANDELL BLACKBURN LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 05/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20174 FRONT ST NE
-----------------------------------------------------
City | POULSBO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98370-7445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-426-0486
-----------------------------------------------------
Fax | 404-426-0486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20174 FRONT ST NE
-----------------------------------------------------
City | POULSBO
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98370-7445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-426-0486
-----------------------------------------------------
Fax | 404-426-0486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | LF60554394
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFT000939
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------