Provider Demographics
NPI:1568666980
Name:BACKES, AMANDA L (PT/LAT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:L
Last Name:BACKES
Suffix:
Gender:F
Credentials:PT/LAT
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:L
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT/LAT
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:515-967-4899
Practice Address - Street 1:3160 8TH ST SW
Practice Address - Street 2:SUITE M&N
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-1023
Practice Address - Country:US
Practice Address - Phone:515-967-4580
Practice Address - Fax:515-967-4899
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008014942225100000X
MO20080149412255A2300X
IA004070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI76580041Medicare Oscar/Certification
MOL35000005Medicare PIN
MO152100002Medicare PIN
VA496670Medicare UPIN