Provider Demographics
NPI:1689292302
Name:BACKFISCH, KIMBERLY (LPC, RPT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:BACKFISCH
Suffix:
Gender:F
Credentials:LPC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3403 BCR 725
Mailing Address - Street 2:
Mailing Address - City:ZALMA
Mailing Address - State:MO
Mailing Address - Zip Code:63787-8769
Mailing Address - Country:US
Mailing Address - Phone:573-275-0269
Mailing Address - Fax:
Practice Address - Street 1:105B N OAK ST
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:MO
Practice Address - Zip Code:63730
Practice Address - Country:US
Practice Address - Phone:573-321-8924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019009248101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional