Provider Demographics
NPI:1679248207
Name:BACKUS, HEATHER RAYNAE (SLPA)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:RAYNAE
Last Name:BACKUS
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388091 E 1134 RD
Mailing Address - Street 2:
Mailing Address - City:WELEETKA
Mailing Address - State:OK
Mailing Address - Zip Code:74880-9794
Mailing Address - Country:US
Mailing Address - Phone:918-623-6467
Mailing Address - Fax:
Practice Address - Street 1:211 E 7TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4607
Practice Address - Country:US
Practice Address - Phone:918-938-0887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKSLPA632355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant