Provider Demographics
NPI:1770827677
Name:BACKUS, LISA JANE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:JANE
Last Name:BACKUS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 537
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-0537
Mailing Address - Country:US
Mailing Address - Phone:860-837-4995
Mailing Address - Fax:
Practice Address - Street 1:129 TOLLAND STAGE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-2342
Practice Address - Country:US
Practice Address - Phone:860-454-0611
Practice Address - Fax:860-454-0919
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003187103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical