Provider Demographics
NPI:1558453100
Name:BACKUS, DENISE S (MSW LICSW)
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:S
Last Name:BACKUS
Suffix:
Gender:F
Credentials:MSW LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1114
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347
Mailing Address - Country:US
Mailing Address - Phone:508-763-9299
Mailing Address - Fax:508-763-9517
Practice Address - Street 1:2A OAK ST
Practice Address - Street 2:STE 201
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649
Practice Address - Country:US
Practice Address - Phone:508-539-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10215041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP06398Medicare ID - Type Unspecified
MAP06398Medicare ID - Type UnspecifiedB