Provider Demographics
NPI:1912063330
Name:BACKER, RONALD M (LPC)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:M
Last Name:BACKER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MARKET SQ
Mailing Address - Street 2:SUITE #6
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2921
Mailing Address - Country:US
Mailing Address - Phone:860-667-1153
Mailing Address - Fax:860-436-4083
Practice Address - Street 1:100 MARKET SQ
Practice Address - Street 2:SUITE #6
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2921
Practice Address - Country:US
Practice Address - Phone:860-667-1153
Practice Address - Fax:860-436-4083
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001361101YP2500X
CT103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT240001361CT07OtherANTHEM
CT334960OtherMHN
CTBACKE-0010OtherCOMPCARE
CT7782664OtherAETNA