Healthcare Provider Details

I. General information

NPI: 1932268646
Provider Name (Legal Business Name): MICHAEL A BACKLUND PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 O BRYNES FERRY RD
JAMESTOWN CA
95327-9102
US

IV. Provider business mailing address

5100 O BRYNES FERRY RD
JAMESTOWN CA
95327-9102
US

V. Phone/Fax

Practice location:
  • Phone: 209-984-5291
  • Fax:
Mailing address:
  • Phone: 209-984-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY13331
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: