Provider Demographics
NPI:1053498113
Name:BACKS, MICHELLE N (OTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:N
Last Name:BACKS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 KNUTSON DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-1133
Mailing Address - Country:US
Mailing Address - Phone:608-301-9387
Mailing Address - Fax:
Practice Address - Street 1:317 KNUTSON DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-1133
Practice Address - Country:US
Practice Address - Phone:608-301-9387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2523-026225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40884800Medicaid