Healthcare Provider Details

I. General information

NPI: 1871389114
Provider Name (Legal Business Name): TRACY R DERICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 WOLFHOUND ST
TIMNATH CO
80547-4488
US

IV. Provider business mailing address

1055 SOUTH ST
WHEATLAND WY
82201-2949
US

V. Phone/Fax

Practice location:
  • Phone: 970-231-0341
  • Fax:
Mailing address:
  • Phone: 307-331-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateWY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: