Dereik Lance Domerese, LCSW

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

2016034259 Issued in MO

Practice address

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

Phone

(816) 223-8522

NPI assigned

Jan 3, 2017

Sex

Male

Sole proprietor

No

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

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

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.

• Mind Shield and Sword Therapy, LLC

  • Clinical Social Worker
  • Lee's Summit, MO
  • NPI 1467181024
  NPD Authorized official

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

{
    "created_epoch": "1483401600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1655251200000",
    "number": "1760927586",
    "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": {
        "last_name": "DOMERESE",
        "first_name": "DEREIK",
        "middle_name": "LANCE",
        "credential": "LCSW",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-01-03",
        "last_updated": "2022-06-15",
        "certification_date": "2022-06-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "KS",
            "license": "10198",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "MO",
            "license": "2016034259",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Laura Brown Doan, M.D.
• Alysse Barrett Doane, FNP
• Mariah R Dobson
• Joey Jenette Doering, MS, CCC-SLP
• Brianna Cullen Doerries
• Dominicks Group Home LLC
• Donna Thomas DDS, PC (Choice Dental Centers)
• John R Donnell, ATC;LAT
• Meghan Kaye Donohue, PTA
• Nicholas Donohue

• Clinical Social Worker in Lee's Summit, MO
• Providers in Lee's 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.