Provider Demographics
NPI:1992766463
Name:TOLLEFSON, DERRIK R (PHD)
Entity type:Individual
Prefix:DR
First Name:DERRIK
Middle Name:R
Last Name:TOLLEFSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:HYRUM
Mailing Address - State:UT
Mailing Address - Zip Code:84319-1604
Mailing Address - Country:US
Mailing Address - Phone:435-621-2992
Mailing Address - Fax:
Practice Address - Street 1:347 S CENTER ST
Practice Address - Street 2:
Practice Address - City:HYRUM
Practice Address - State:UT
Practice Address - Zip Code:84319-1604
Practice Address - Country:US
Practice Address - Phone:435-621-2992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT295335-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health