1265949234 NPI number — DR. ELIZABETH NICOLE STCLAIR PSYD

Table of content: DR. ELIZABETH NICOLE STCLAIR PSYD (NPI 1265949234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265949234 NPI number — DR. ELIZABETH NICOLE STCLAIR PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STCLAIR
Provider First Name:
ELIZABETH
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSYD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265949234
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 BROADWAY SUITE 100
Provider Second Line Business Mailing Address:
PMB 94974
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98402-1407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-541-3659
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3757 FREIGHTER PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREMERTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98312-5503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-830-6083
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/29/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: PY60881040 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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