1104318526 NPI number — DR. TERREL BACKES LICENSED PSYCHOLOGIS

Table of content: DR. TERREL BACKES LICENSED PSYCHOLOGIS (NPI 1104318526)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104318526 NPI number — DR. TERREL BACKES LICENSED PSYCHOLOGIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKES
Provider First Name:
TERREL
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
LICENSED PSYCHOLOGIS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104318526
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2333 NEAL AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AFTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55001-9765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-276-1787
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2712 FREMONT AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55408-1122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-872-8218
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  LP5908 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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