Provider Demographics
NPI:1790124311
Name:BACKSTROM, LAUREL ANDVIK (PT)
Entity Type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:ANDVIK
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 NORTHWEST LN SE
Mailing Address - Street 2:SUITE B
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-6908
Mailing Address - Country:US
Mailing Address - Phone:360-456-5154
Mailing Address - Fax:360-456-0844
Practice Address - Street 1:1450 NORTHWEST LN SE
Practice Address - Street 2:SUITE B
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6908
Practice Address - Country:US
Practice Address - Phone:360-456-5154
Practice Address - Fax:360-456-0844
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT0000912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist