Provider Demographics
NPI:1063714343
Name:BACKSTROM, ELSA (MA LPCC)
Entity type:Individual
Prefix:
First Name:ELSA
Middle Name:
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 VIA CABALLERO DEL SUR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5333
Mailing Address - Country:US
Mailing Address - Phone:505-699-9762
Mailing Address - Fax:
Practice Address - Street 1:2795 VIA CABALLERO DEL SUR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5333
Practice Address - Country:US
Practice Address - Phone:505-699-9762
Practice Address - Fax:505-780-5123
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0157651101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health