Provider Demographics
NPI:1003981101
Name:BACKMAN, STEPHANIE ANN (LICSW)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:ANN
Last Name:BACKMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 164
Mailing Address - Street 2:
Mailing Address - City:WELLFLEET
Mailing Address - State:MA
Mailing Address - Zip Code:02667-0164
Mailing Address - Country:US
Mailing Address - Phone:508-255-2322
Mailing Address - Fax:508-255-2399
Practice Address - Street 1:165 RT 6A
Practice Address - Street 2:
Practice Address - City:ORLEANS
Practice Address - State:MA
Practice Address - Zip Code:02653-3267
Practice Address - Country:US
Practice Address - Phone:508-255-2322
Practice Address - Fax:508-255-2399
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1059221041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA105922OtherLICENSEDINDEPCLIN SOCIALW
MA105922OtherLICENSEDINDEPCLIN SOCIALW