Provider Demographics
NPI:1699106427
Name:BACKOUS, DIANE LYNN
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:LYNN
Last Name:BACKOUS
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 1:10929 NE 75TH ST
Mailing Address - Street 2:
Mailing Address - City:BONDURANT
Mailing Address - State:IA
Mailing Address - Zip Code:50035-1146
Mailing Address - Country:US
Mailing Address - Phone:515-779-8850
Mailing Address - Fax:
Practice Address - Street 1:10929 NE 75TH ST
Practice Address - Street 2:
Practice Address - City:BONDURANT
Practice Address - State:IA
Practice Address - Zip Code:50035-1146
Practice Address - Country:US
Practice Address - Phone:515-779-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program