Provider Demographics
NPI:1760846224
Name:TYGART, DEIDRE L (CAC III)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:L
Last Name:TYGART
Suffix:
Gender:F
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 E 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:COMMERCE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:80022-4714
Mailing Address - Country:US
Mailing Address - Phone:303-321-2533
Mailing Address - Fax:
Practice Address - Street 1:14311 E 4TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-8703
Practice Address - Country:US
Practice Address - Phone:303-513-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACC 0006214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)