Provider Demographics
NPI:1871528364
Name:BACKSTROM, SHERRILL HOPE (PT)
Entity type:Individual
Prefix:
First Name:SHERRILL
Middle Name:HOPE
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8419
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8087
Mailing Address - Country:US
Mailing Address - Phone:228-388-5714
Mailing Address - Fax:228-388-0017
Practice Address - Street 1:316 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-6504
Practice Address - Country:US
Practice Address - Phone:601-394-4545
Practice Address - Fax:601-394-4546
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09015077Medicaid
MSDD4538/P00716895OtherMEDICARE RAILROAD
MSDD4538OtherRAILROAD MEDICARE
MS1033218524OtherGROUP NPI
MSDD4538/P00716895OtherMEDICARE RAILROAD