Healthcare Provider Details

I. General information

NPI: 1063714343
Provider Name (Legal Business Name): ELSA BACKSTROM M.A LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2010
Last Update Date: 01/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2795 VIA CABALLERO DEL SUR
SANTA FE NM
87505-5333
US

IV. Provider business mailing address

2795 VIA CABALLERO DEL SUR
SANTA FE NM
87505-5333
US

V. Phone/Fax

Practice location:
  • Phone: 505-699-9762
  • Fax: 505-780-5123
Mailing address:
  • Phone: 505-699-9762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0157651
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: