Provider Demographics
NPI:1720558745
Name:BACK, LEON O IV (LICSW)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:O
Last Name:BACK
Suffix:IV
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 BAKER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4417
Mailing Address - Country:US
Mailing Address - Phone:401-781-2400
Mailing Address - Fax:401-781-2687
Practice Address - Street 1:78 BAKER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4417
Practice Address - Country:US
Practice Address - Phone:401-781-2400
Practice Address - Fax:401-781-2687
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW038761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical