Provider Demographics
NPI:1437633658
Name:BACKE, THOMAS KENNETH (PT, DPT, CLT)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:KENNETH
Last Name:BACKE
Suffix:
Gender:M
Credentials:PT, DPT, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16420 W US HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:CO
Mailing Address - Zip Code:80863-8760
Mailing Address - Country:US
Mailing Address - Phone:719-374-6172
Mailing Address - Fax:719-374-6118
Practice Address - Street 1:16420 W US HIGHWAY 24
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:CO
Practice Address - Zip Code:80863-8760
Practice Address - Country:US
Practice Address - Phone:719-374-6172
Practice Address - Fax:719-374-6118
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015815225100000X
VA2305212280225100000X
NH4430225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist