Healthcare Provider Details

I. General information

NPI: 1477738615
Provider Name (Legal Business Name): MARVIN H. BACKER, PH.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2008
Last Update Date: 01/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E MAIN ST SUITE 203
BOZEMAN MT
59715-6240
US

IV. Provider business mailing address

222 E MAIN ST SUITE 203
BOZEMAN MT
59715-6240
US

V. Phone/Fax

Practice location:
  • Phone: 406-587-9558
  • Fax: 406-587-0534
Mailing address:
  • Phone: 406-587-9558
  • Fax: 406-587-0534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number80
License Number StateMT

VIII. Authorized Official

Name: DR. MARVIN HOWARD BACKER
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 406-587-9558