Provider Demographics
NPI:1396128294
Name:BACKMON, GHISLAINE
Entity type:Individual
Prefix:
First Name:GHISLAINE
Middle Name:
Last Name:BACKMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-2726
Mailing Address - Country:US
Mailing Address - Phone:980-833-5426
Mailing Address - Fax:
Practice Address - Street 1:80 PEARL ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-2726
Practice Address - Country:US
Practice Address - Phone:980-833-5426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-09
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health