Healthcare Provider Details

I. General information

NPI: 1588575674
Provider Name (Legal Business Name): BRIANNA BACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E GLENLORD RD
SAINT JOSEPH MI
49085-9342
US

IV. Provider business mailing address

9090 N MAIN ST APT 26
BERRIEN SPRINGS MI
49103-1589
US

V. Phone/Fax

Practice location:
  • Phone: 269-926-3626
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7152001273
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: