Provider Demographics
NPI:1689972325
Name:DIERKSEN, TRACY (MSW, LCSW, PLADC, RN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:DIERKSEN
Suffix:
Gender:F
Credentials:MSW, LCSW, PLADC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 S GIBSON ST
Mailing Address - Street 2:PO BOX 86
Mailing Address - City:HAY SPRINGS
Mailing Address - State:NE
Mailing Address - Zip Code:69347-4208
Mailing Address - Country:US
Mailing Address - Phone:308-638-4411
Mailing Address - Fax:308-638-4412
Practice Address - Street 1:226 S GIBSON ST
Practice Address - Street 2:
Practice Address - City:HAY SPRINGS
Practice Address - State:NE
Practice Address - Zip Code:69347-4208
Practice Address - Country:US
Practice Address - Phone:308-638-4411
Practice Address - Fax:308-638-4412
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-04
Last Update Date:2012-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE53412163W00000X
NE1456, 40911041C0700X
NEP-1077101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163W00000XNursing Service ProvidersRegistered Nurse
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)