Healthcare Provider Details

I. General information

NPI: 1285251967
Provider Name (Legal Business Name): SOMATIC REVELATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2020
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 E GRAND AVE STE 421 & 412
LARAMIE WY
82070-4370
US

IV. Provider business mailing address

PO BOX 594
LARAMIE WY
82073-0594
US

V. Phone/Fax

Practice location:
  • Phone: 307-200-9228
  • Fax: 307-460-9084
Mailing address:
  • Phone: 307-200-9228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225600000X
TaxonomyDance Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. TYLER S. TEDMON-JONES
Title or Position: PROVIDER/OWNER
Credential: PHD
Phone: 307-200-9228