Provider Demographics
NPI:1801293030
Name:BACKMAN, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BACKMAN
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:S1222 MATHISON LN
Mailing Address - Street 2:
Mailing Address - City:WESTBY
Mailing Address - State:WI
Mailing Address - Zip Code:54667-7266
Mailing Address - Country:US
Mailing Address - Phone:385-313-0547
Mailing Address - Fax:
Practice Address - Street 1:370 E SOUTH TEMPLE STE 550
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1237
Practice Address - Country:US
Practice Address - Phone:385-313-0547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10846080-6009101YM0800X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner