Provider Demographics
NPI:1265124580
Name:BACKENROTH, FELICIA
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:BACKENROTH
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 1:199 ROSEWOOD DR STE 250
Mailing Address - Street 2:
Mailing Address - City:DANVERS
Mailing Address - State:MA
Mailing Address - Zip Code:01923-1684
Mailing Address - Country:US
Mailing Address - Phone:978-968-1700
Mailing Address - Fax:
Practice Address - Street 1:35 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-5529
Practice Address - Country:US
Practice Address - Phone:978-620-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA202204175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist