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General NPI Number Information
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NPI Number | 1982836391
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Entity Type | Organization
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Legal Business Name | BACK DOOR, LLC
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Dates
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Enumeration Date | 08/18/2009
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Last Update Date | 11/17/2009
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Provider Practice Location Address
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Address Line | 1639 CAPE CORAL PKWY E STE 211
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City | CAPE CORAL
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State | FL
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Zip | 33904-9657
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Country | US
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Telephone | 239-745-5917
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Fax | 866-676-2762
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Provider Business Mailing Address
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Address Line | 1639 CAPE CORAL PKWY E STE 211
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City | CAPE CORAL
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State | FL
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Zip | 33904-9657
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Country | US
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Telephone | 239-745-5917
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Fax | 866-676-2762
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | CHERYL L BUSS
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Credential | LCSW
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Telephone | 239-745-5917
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number | ME100060
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW8039
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License Number State | FL
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