Provider Demographics
NPI:1952872459
Name:BACKUS, WAYNE (LMSW)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:BACKUS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 AUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1022
Mailing Address - Country:US
Mailing Address - Phone:718-762-7633
Mailing Address - Fax:
Practice Address - Street 1:2833 W AVENUE K12 APT 232
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-1191
Practice Address - Country:US
Practice Address - Phone:917-318-3519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-09
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0936611041C0700X
NY103026252Y00000X
CA1142011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No252Y00000XAgenciesEarly Intervention Provider Agency