Healthcare Provider Details

I. General information

NPI: 1134333107
Provider Name (Legal Business Name): MICHELLE BACK LCSW-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 RADIO STATION ROAD
LAPLATA MD
20646
US

IV. Provider business mailing address

3175 W WARD RD 200
DUNKIRK MD
20754-3020
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-9887
  • Fax: 301-609-7284
Mailing address:
  • Phone: 410-286-0664
  • Fax: 410-286-2834

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13796
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: