Healthcare Provider Details

I. General information

NPI: 1578592812
Provider Name (Legal Business Name): BLAINE EVAN HUBBARD LPC, LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 W HARVARD ST
SILOAM SPRINGS AR
72761-4013
US

IV. Provider business mailing address

2400 S 48TH ST
SPRINGDALE AR
72762-6683
US

V. Phone/Fax

Practice location:
  • Phone: 479-549-3121
  • Fax: 479-750-4843
Mailing address:
  • Phone: 479-750-2020
  • Fax: 479-750-4843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberP0412055
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberM0502004
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: