Provider Demographics
NPI:1477630143
Name:BACK, SHERRI
Entity Type:Individual
Prefix:
First Name:SHERRI
Middle Name:
Last Name:BACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4925 PALOMINO TRL
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-9551
Mailing Address - Country:US
Mailing Address - Phone:317-862-8695
Mailing Address - Fax:
Practice Address - Street 1:5005 E STOP 11 RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9447
Practice Address - Country:US
Practice Address - Phone:317-865-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN31002422AOtherLICENSE#