Healthcare Provider Details

I. General information

NPI: 1073131736
Provider Name (Legal Business Name): LANNA M BACKEN BS ACT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 HAINES AVE STE 6
RAPID CITY SD
57701-0710
US

IV. Provider business mailing address

1520 HAINES AVE STE 6
RAPID CITY SD
57701-0710
US

V. Phone/Fax

Practice location:
  • Phone: 605-716-7841
  • Fax: 605-718-0404
Mailing address:
  • Phone: 605-716-7841
  • Fax: 605-718-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier19693810245
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: