Provider Demographics
NPI:1225503279
Name:BACKES, BENJAMIN (LADC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BACKES
Suffix:
Gender:M
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 MILL ST APT 533
Mailing Address - Street 2:
Mailing Address - City:EAST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06512-1071
Mailing Address - Country:US
Mailing Address - Phone:203-671-0917
Mailing Address - Fax:
Practice Address - Street 1:251 MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2357
Practice Address - Country:US
Practice Address - Phone:860-388-9656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT44.001308101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)