Provider Demographics
NPI:1700640695
Name:BACKOWSKI, COLLIN ROSS
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:ROSS
Last Name:BACKOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26297 139TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT RIPLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56449-2060
Mailing Address - Country:US
Mailing Address - Phone:320-630-7967
Mailing Address - Fax:
Practice Address - Street 1:26297 139TH AVE
Practice Address - Street 2:
Practice Address - City:FORT RIPLEY
Practice Address - State:MN
Practice Address - Zip Code:56449-2060
Practice Address - Country:US
Practice Address - Phone:320-630-7967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
MN171M00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator