Provider Demographics
NPI:1871389114
Name:DERICKSON, TRACY R
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:R
Last Name:DERICKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:WHEATLAND
Mailing Address - State:WY
Mailing Address - Zip Code:82201-2949
Mailing Address - Country:US
Mailing Address - Phone:307-331-7899
Mailing Address - Fax:
Practice Address - Street 1:1272 WOLFHOUND ST
Practice Address - Street 2:
Practice Address - City:TIMNATH
Practice Address - State:CO
Practice Address - Zip Code:80547-4488
Practice Address - Country:US
Practice Address - Phone:970-231-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health