Provider Demographics
NPI:1306013420
Name:BURGESS-BACKERT, FAY (MS OTR)
Entity Type:Individual
Prefix:
First Name:FAY
Middle Name:
Last Name:BURGESS-BACKERT
Suffix:
Gender:F
Credentials:MS OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WYMAN RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-3237
Mailing Address - Country:US
Mailing Address - Phone:347-307-0249
Mailing Address - Fax:
Practice Address - Street 1:5 WYMAN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02420-3237
Practice Address - Country:US
Practice Address - Phone:347-307-0249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9620225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist