Provider Demographics
NPI:1245003979
Name:BLUE, AMY (LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BLUE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 PEACH BLOSSOM
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3555
Mailing Address - Country:US
Mailing Address - Phone:913-553-7644
Mailing Address - Fax:
Practice Address - Street 1:910 SE 21ST ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-9776
Practice Address - Country:US
Practice Address - Phone:913-553-7644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA2209010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health