MEDICARE: TRACY DIERKSEN MSW, LCSW, PLADC, RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	53412	NE
2	1041C0700X	Clinical Social Worker	1456, 4091	NE
3	101YA0400X	Addiction (Substance Use Disorder) Counselor	P-1077	NE

General Provider Information

NPI Number	:	1689972325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACY DIERKSEN MSW, LCSW, PLADC, RN

Provider Business Mailing Address
First Line	:	226 S GIBSON ST
Second Line	:	PO BOX 86
City	:	HAY SPRINGS
State	:	NE
Zip	:	69347-4208
Country	:	US
Telephone Number	:	308-638-4411
Fax Number	:	308-638-4412

Provider Business Practice Location Address
First Line	:	226 S GIBSON ST
Second Line	:
City	:	HAY SPRINGS
State	:	NE
Zip	:	69347-4208
Country	:	US
Telephone Number	:	308-638-4411
Fax Number	:	308-638-4412

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2011
Last Update Date	:	10/28/2012

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