Derra Gullickson, MA, PSYD

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

10979353-2501 Issued in UT

Practice address

750 N Freedom Blvd
Provo, UT 84601-1677

Phone

(801) 373-4760

Fax

(801) 373-0639

NPI assigned

Jun 21, 2017

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in UT

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Arts

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Wasatch Behavioral Health Special Service District

  • Community/Behavioral Health Agency
  • Provo, UT
  • NPI 1356357115
  Medicare reassignment NPD
• Wasatch Behavioral Health Special Service District

  • Clinical Medical Laboratory
  • Orem, UT
  • NPI 1669257556
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1498003200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1572480000000",
    "number": "1255851333",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "750 N FREEDOM BLVD",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846011677",
            "telephone_number": "801-373-4760"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "750 N FREEDOM BLVD",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846011677",
            "telephone_number": "801-373-4760",
            "fax_number": "801-373-0639"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "705 N Freedom Blvd.",
            "address_purpose": "LOCATION",
            "city": "Provo",
            "state": "UT",
            "postal_code": "84601",
            "country_code": "US",
            "telephone_number": "612-910-6371",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "GULLICKSON",
        "first_name": "DERRA",
        "credential": "MA, PSYD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2017-06-21",
        "last_updated": "2019-10-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "UT",
            "license": "10979353-2501",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Guided Eating, LLC
• Jennifer Alea Guinto
• Erik Paul Gulbrandsen, D.O.
• Korlyn Gulbranson, ATC
• Aspen Gulley
• Rachel Gunderson, AGACNP-BC
• Madhumathy Gundlapalli, MD
• Jonathan B Gunther, M.D.
• Cailey Gurule
• Margaret L Gustafson, PHD

• Clinical Psychologist in Provo, UT
• Providers in Provo, UT by specialty
• Clinical Psychologist in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 31, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.