Provider Demographics
NPI:1962154161
Name:BACKERT, ANTONETTE
Entity type:Individual
Prefix:
First Name:ANTONETTE
Middle Name:
Last Name:BACKERT
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 1:6491 BURKE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:NY
Mailing Address - Zip Code:14085-9733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6491 BURKE RD
Practice Address - Street 2:
Practice Address - City:LAKE VIEW
Practice Address - State:NY
Practice Address - Zip Code:14085-9733
Practice Address - Country:US
Practice Address - Phone:716-200-6828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2770144103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool