Provider Demographics
NPI:1003030511
Name:DEITRICH-MACLEAN, VIVIAN GAY (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:GAY
Last Name:DEITRICH-MACLEAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:GAY
Other - Middle Name:
Other - Last Name:DEITRICH-MACLEAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:507 S 4TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-3729
Mailing Address - Country:US
Mailing Address - Phone:307-755-1982
Mailing Address - Fax:
Practice Address - Street 1:507 S 4TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-3729
Practice Address - Country:US
Practice Address - Phone:307-755-1982
Practice Address - Fax:307-742-4089
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY291103TC0700X, 103T00000X, 103TC2200X, 103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119587500Medicaid