Provider Demographics
NPI:1760646756
Name:BACKER, DAWN LYNETTE (CLVT)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:LYNETTE
Last Name:BACKER
Suffix:
Gender:F
Credentials:CLVT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 W 11TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-2589
Mailing Address - Country:US
Mailing Address - Phone:605-367-5260
Mailing Address - Fax:
Practice Address - Street 1:2900 W 11TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-2589
Practice Address - Country:US
Practice Address - Phone:605-367-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4490251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1174785992Medicaid
SD1174785992Medicare Oscar/Certification
SD1174785992Medicare PIN
SD1174785992Medicare UPIN
SD1174785992Medicare NSC