Provider Demographics
NPI:1013320852
Name:BACKER, WINSOME (COTAQ)
Entity Type:Individual
Prefix:
First Name:WINSOME
Middle Name:
Last Name:BACKER
Suffix:
Gender:F
Credentials:COTAQ
Other - Prefix:
Other - First Name:WINSOME
Other - Middle Name:E
Other - Last Name:PAULMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:SUTHERLAND
Mailing Address - State:NE
Mailing Address - Zip Code:69165
Mailing Address - Country:US
Mailing Address - Phone:908-386-4393
Mailing Address - Fax:
Practice Address - Street 1:333 MAPLE ST
Practice Address - Street 2:
Practice Address - City:SUTHERLAND
Practice Address - State:NE
Practice Address - Zip Code:69165-3000
Practice Address - Country:US
Practice Address - Phone:908-386-4393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE883224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant