=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689972325
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACY DIERKSEN MSW, LCSW, PLADC, RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2011
-----------------------------------------------------
Last Update Date | 10/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 226 S GIBSON ST
-----------------------------------------------------
City | HAY SPRINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69347-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-638-4411
-----------------------------------------------------
Fax | 308-638-4412
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 226 S GIBSON ST PO BOX 86
-----------------------------------------------------
City | HAY SPRINGS
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 69347-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 308-638-4411
-----------------------------------------------------
Fax | 308-638-4412
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 53412
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 1456, 4091
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | P-1077
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------