Provider Demographics
NPI:1518988765
Name:BACKUS, BRUCE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:BACKUS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 PUNCH BROOK RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-1814
Mailing Address - Country:US
Mailing Address - Phone:860-673-5949
Mailing Address - Fax:
Practice Address - Street 1:674 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-4288
Practice Address - Country:US
Practice Address - Phone:860-233-6228
Practice Address - Fax:860-233-2371
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000-998103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4061628Medicaid
CT4061628Medicaid