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NPI Code Detail

MEDICARE: BLAINE EVAN HUBBARD LPC, LMFT

MEDICARE: BLAINE EVAN HUBBARD LPC, LMFT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YP2500XProfessional CounselorP0412055AR
2106H00000XMarriage & Family TherapistM0502004AR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
15Y327OTHERARBLUE SHIELD PROVIDER #

General Provider Information

NPI Number : 1578592812
Entity Type Code : Individual
Provider Name (Legal Business Name) : BLAINE EVAN HUBBARD LPC, LMFT
Provider Business Mailing Address
First Line : 2400 S 48TH ST
Second Line :
City : SPRINGDALE
State : AR
Zip : 72762-6683
Country : US
Telephone Number : 479-750-2020
Fax Number : 479-750-4843
Provider Business Practice Location Address
First Line : 827 W HARVARD ST
Second Line :
City : SILOAM SPRINGS
State : AR
Zip : 72761-4013
Country : US
Telephone Number : 479-549-3121
Fax Number : 479-750-4843
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2006
Last Update Date : 07/13/2016

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