Provider Demographics
NPI:1083734768
Name:BACKUS, HENRY BERNARD
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:BERNARD
Last Name:BACKUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 NEW HOPE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-1415
Mailing Address - Country:US
Mailing Address - Phone:843-664-0295
Mailing Address - Fax:
Practice Address - Street 1:2109 NEW HOPE DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-1415
Practice Address - Country:US
Practice Address - Phone:843-664-0295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376241Medicaid
SC376241Medicaid