Mind Shield and Sword Therapy, LLC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

Legal business name

MIND SHIELD AND SWORD THERAPY, LLC

Practice address

905 NE Rice Rd Ste B
Lees Summit, MO 64086-6300

Phone

(816) 223-8522

NPI assigned

Jun 8, 2022

Organization subpart

No

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

Authorized official

Name

Mr. Dereik Lance Domerese, LCSWNPI 1760927586

Title

Owner/Member

Phone

(816) 223-8522

Specialties & licenses 2

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Dereik Lance Domerese, LCSW

  • Clinical Social Worker
  • Lees Summit, MO
  • NPI 1760927586
  NPD Authorized official

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

{
    "created_epoch": "1654646400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1655251200000",
    "number": "1467181024",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2410 SW STATE ROUTE 150",
            "city": "LEES SUMMIT",
            "state": "MO",
            "postal_code": "640822903",
            "telephone_number": "816-223-8522"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "905 NE RICE RD STE B",
            "city": "LEES SUMMIT",
            "state": "MO",
            "postal_code": "640866300",
            "telephone_number": "816-223-8522"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIND SHIELD AND SWORD THERAPY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-06-08",
        "last_updated": "2022-06-15",
        "certification_date": "2022-06-15",
        "status": "A",
        "authorized_official_last_name": "DOMERESE",
        "authorized_official_first_name": "DEREIK",
        "authorized_official_middle_name": "LANCE",
        "authorized_official_title_or_position": "OWNER/MEMBER",
        "authorized_official_telephone_number": "816-223-8522",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "LCSW"
    },
    "taxonomies": [
        {
            "code": "104100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Nichela Miller
• Rynda Jo Miller, LPC
• Samantha J Miller, LPC
• Steve D Miller, DC
• David Michael Millward, DPM
• Mine Divine Health LLC
• Kevin Ray Minnick, DPT
• Angela Wozniak Minor, PHD
• Tammy Rayann Minshall, FNP-C
• Mint Dental Summit LLC

• Clinical Social Worker in Lees Summit, MO
• Providers in Lees Summit, MO by specialty
• Clinical Social Worker in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 15, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.