Provider Demographics
NPI:1104107911
Name:BACKIS, ALEXANDRA (LCSW)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:BACKIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 WILLOUGHBY AVE
Mailing Address - Street 2:3F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-3373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1751 PARK AVE
Practice Address - Street 2:BAILEY HOUSE
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-2831
Practice Address - Country:US
Practice Address - Phone:212-289-6008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-07
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0148071041C0700X
NY72 088102104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical