Provider Demographics
NPI:1871782805
Name:BACKUS, KATHLEEN (MA, LCPC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BACKUS
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2203 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-4322
Mailing Address - Country:US
Mailing Address - Phone:309-663-0781
Mailing Address - Fax:
Practice Address - Street 1:808 S ELDORADO RD STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6075
Practice Address - Country:US
Practice Address - Phone:309-212-6007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004305101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional