Provider Demographics
NPI:1114762911
Name:BACKHAUS, KELLI RAE
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:RAE
Last Name:BACKHAUS
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 1:1616 W 6TH ST APT 323
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78703-5011
Mailing Address - Country:US
Mailing Address - Phone:512-608-7647
Mailing Address - Fax:
Practice Address - Street 1:1616 W 6TH ST APT 323
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78703-5011
Practice Address - Country:US
Practice Address - Phone:512-608-7647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT121927225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist