Healthcare Provider Details

I. General information

NPI: 1316456643
Provider Name (Legal Business Name): GINA LABETH BREWER LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 HIGHWAY 62 E
MOUNTAIN HOME AR
72653-2708
US

IV. Provider business mailing address

PO BOX 497
AUGUSTA AR
72006-0497
US

V. Phone/Fax

Practice location:
  • Phone: 870-970-7140
  • Fax: 870-701-3181
Mailing address:
  • Phone: 870-347-2534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: