Provider Demographics
NPI:1447714647
Name:BACKSTROM, KIMBERLEY ANNE
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ANNE
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7715 ORNAMENTO WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89179-1825
Mailing Address - Country:US
Mailing Address - Phone:702-247-1145
Mailing Address - Fax:
Practice Address - Street 1:300 E CHARLESTON BLVD STE 216
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-1042
Practice Address - Country:US
Practice Address - Phone:702-247-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW87254101YM0800X
NV1358P-S104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health