Provider Demographics
NPI:1306195433
Name:BACKUS, ELIZABETH (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BACKUS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1014 FORSYTH ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2051
Mailing Address - Country:US
Mailing Address - Phone:478-633-8100
Mailing Address - Fax:478-633-6268
Practice Address - Street 1:1014 FORSYTH ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2051
Practice Address - Country:US
Practice Address - Phone:478-633-2742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-05
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008288235Z00000X, 235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASLP 008288OtherGA LICENSE