Provider Demographics
NPI:1902135205
Name:BACKSTROM, TAMI LYNN (LMT)
Entity Type:Individual
Prefix:MS
First Name:TAMI
Middle Name:LYNN
Last Name:BACKSTROM
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7193 DOUGLAS BLVD STE 103A
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1540
Mailing Address - Country:US
Mailing Address - Phone:770-845-4407
Mailing Address - Fax:
Practice Address - Street 1:7193 DOUGLAS BLVD STE 103A
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1540
Practice Address - Country:US
Practice Address - Phone:770-845-4407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005428171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor