Provider Demographics
NPI:1962001909
Name:BACKAUS, WENDY M (RDN)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:M
Last Name:BACKAUS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:
Other - Last Name:BARTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 W ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BLACK RIVER FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54615-5052
Mailing Address - Country:US
Mailing Address - Phone:715-284-5361
Mailing Address - Fax:
Practice Address - Street 1:711 W ADAMS ST
Practice Address - Street 2:
Practice Address - City:BLACK RIVER FALLS
Practice Address - State:WI
Practice Address - Zip Code:54615-5052
Practice Address - Country:US
Practice Address - Phone:715-284-5361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3663-29133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI86118957OtherCDR CERTIFICATION