Individual
DERRA GULLICKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MA, PSYD
Contact information
Practice address
750 N FREEDOM BLVD, PROVO, UT 84601-1677
(801) 373-4760
(801) 373-0639
Mailing address
750 N FREEDOM BLVD, PROVO, UT 84601-1677
(801) 373-4760
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
10979353-2501
UT
Other
Enumeration date
06/21/2017
Last updated
10/31/2019
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