Provider Demographics
NPI:1568697910
Name:BACKUS-MCCLOY, KIMBERLY ANNIE (MS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANNIE
Last Name:BACKUS-MCCLOY
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1035
Mailing Address - Country:US
Mailing Address - Phone:304-927-1007
Mailing Address - Fax:
Practice Address - Street 1:825 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1035
Practice Address - Country:US
Practice Address - Phone:304-927-1007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0457235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist