DERRA GULLICKSON MA, PSYD
NPI 1255851333
Psychologist - Clinical in Provo, UT

Q: What is Derra Gullickson's NPI number?

The NPI number for Derra Gullickson is 1255851333. It was assigned to this individual provider in the NPPES registry on June 21, 2017.

Q: What is Derra Gullickson's specialty?

The primary specialty registered for this NPI is Psychologist, specializing in Clinical, with taxonomy code 103TC0700X.

Q: When was this NPI record last updated?

The NPPES record for Derra Gullickson was last updated on October 31, 2019. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 6 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.

Active since June 21, 2017PECOS EnrolledAccepts Medicare Assignment

750 N FREEDOM BLVD, PROVO, UT 84601(801) 373-4760(801) 373-0639 Get Directions Write a Review

NPPES record last updated: October 31, 2019. Verified against the NPPES registry weekly; last sync: August 02, 2026.

Record update history: Oct 31, 2019, Jun 21, 2017 (2 updates tracked since 2017).

On this page

About Derra Gullickson Ma, Psyd NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

DERRA GULLICKSON MA, PSYD (NPI 1255851333) is an individual clinical provider in Provo, Utah, licensed in Utah (10979353-2501) and active in the NPI registry since June 2017. She is enrolled in Medicare PECOS, maintains a secondary practice location in Provo, and is a graduate of Other (2018).

NPPES Registry Identity

NPI1255851333

Entity TypeIndividualFemale

Primary Taxonomy103TC0700X

Provider Legal NameDERRA GULLICKSONCredential: MA, PSYD

Location Address750 N FREEDOM BLVDProvo, UT 84601-1677

Mailing Address750 N Freedom BlvdProvo, UT 84601-1677 · (801) 373-4760

Phone(801) 373-4760

Fax(801) 373-0639

Sole ProprietorNo

Medical School CMSOtherGraduated 2018

Enumeration DateJune 21, 2017

Last NPPES UpdateOctober 31, 20192 updates tracked since enumeration

✔ NPI 1255851333 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyPsychologist · ClinicalBehavioral Health & Social Service Providers

Taxonomy Code103TC0700X

License✔ Licensed in UT · 10979353-2501

Definition

A psychologist who provides continuing and comprehensive mental and behavioral health care for individuals and families; consultation to agencies and communities; training, education and supervision; and research-based practice. It is a specialty in breadth -- one that is broadly inclusive of severe psychopathology -- and marked by comprehensiveness and integration of knowledge and skill from a broad array of disciplines within and outside of psychology proper. The scope of clinical psychology encompasses all ages, multiple diversities and varied systems.

750 N FREEDOM BLVD, Provo, UT 84601

Open in Google Maps ↗

Secondary Practice Location 1

Location 1705 N Freedom Blvd.Provo, UT 84601 · Phone (612) 910-6371

Accepted Insurance

The full list of accepted plans is on the Insurance tab. Issuers include BridgeSpan Health Company, Regence BlueCross BlueShield of Utah, Select Health.Insurance ›

Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare and accepts Medicare assignment

Derra Gullickson Ma, Psyd is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.

PECOS PAC ID8224461926

PECOS Enrollment IDI20191211001458

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment– Home Health Agency– Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.

Physician Visit Costs CMS claims · ZIP area

Typical Medicare office-visit costs in the 84601 ZIP code area, from fee-for-service claims. These are area statistics, not this provider’s prices; actual charges vary by service and coverage.

New Patient

$166.03 typical visit price

range $54.34 – $166.03

Typical copayment $41.50 (range $13.58 – $41.50)

Most-billed visit code 99205

Established Patient

$96.35 typical visit price

range $17.23 – $135.20

Typical copayment $24.08 (range $4.30 – $33.80)

Most-billed visit code 99214

Amounts reflect what Medicare beneficiaries in this ZIP area are typically charged for office visits. Patients with other coverage should check their individual plans.

Other Providers at the Same Location NPPES 20

Providers registered at the same practice address, or within the immediate area, according to the NPPES registry.

ELIZA RACHELLE GEDGE PH.D., LP

Psychologist (Clinical)