1912063330 NPI number — RONALD M BACKER LPC

Table of content: RONALD M BACKER LPC (NPI 1912063330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912063330 NPI number — RONALD M BACKER LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BACKER
Provider First Name:
RONALD
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1912063330
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 MARKET SQ
Provider Second Line Business Mailing Address:
SUITE #6
Provider Business Mailing Address City Name:
NEWINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06111-2921
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-667-1153
Provider Business Mailing Address Fax Number:
860-436-4083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MARKET SQ
Provider Second Line Business Practice Location Address:
SUITE #6
Provider Business Practice Location Address City Name:
NEWINGTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06111-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-667-1153
Provider Business Practice Location Address Fax Number:
860-436-4083
Provider Enumeration Date:
12/29/2006

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: 101YP2500X , with the licence number:  001361 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 103TS0200X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 240001361CT07 . This is a "ANTHEM" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 334960 . This is a "MHN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: BACKE-0010 . This is a "COMPCARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 7782664 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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