Healthcare Provider Details

I. General information

NPI: 1144903535
Provider Name (Legal Business Name): JOHN BACKFISCH LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2023
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19806 STATE HIGHWAY C
ADVANCE MO
63730-8352
US

IV. Provider business mailing address

19806 STATE HIGHWAY C
ADVANCE MO
63730-8352
US

V. Phone/Fax

Practice location:
  • Phone: 573-321-8924
  • Fax:
Mailing address:
  • Phone: 573-321-8924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2022034386
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: