Provider Demographics
NPI:1285758243
Name:BACKER, BARRY MICHAEL (MFT)
Entity type:Individual
Prefix:MR
First Name:BARRY
Middle Name:MICHAEL
Last Name:BACKER
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 MARTIN LUTHER KING JR BLVD STE 612
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3537
Mailing Address - Country:US
Mailing Address - Phone:310-603-2795
Mailing Address - Fax:
Practice Address - Street 1:3737 MARTIN LUTHER KING JR BLVD STE 612
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3537
Practice Address - Country:US
Practice Address - Phone:310-603-2795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30292106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist