Healthcare Provider Details

I. General information

NPI: 1275470718
Provider Name (Legal Business Name): GUADALUPE BLAS III LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7167 HIGHWAY 38
EVARTS KY
40828-6331
US

IV. Provider business mailing address

7167 HIGHWAY 38
EVARTS KY
40828-6331
US

V. Phone/Fax

Practice location:
  • Phone: 606-795-5443
  • Fax:
Mailing address:
  • Phone: 606-795-5443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number297004
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: