Provider Demographics
NPI:1902385388
Name:VICKERS, TYRA B (PHD)
Entity Type:Individual
Prefix:DR
First Name:TYRA
Middle Name:B
Last Name:VICKERS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12151 W MOUNT POWELL
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80127-3201
Mailing Address - Country:US
Mailing Address - Phone:303-304-6657
Mailing Address - Fax:
Practice Address - Street 1:5860 S CURTICE ST
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-1909
Practice Address - Country:US
Practice Address - Phone:720-316-3909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO39807103TS0200X
CO13939103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103T00000XBehavioral Health & Social Service ProvidersPsychologist