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General NPI Number Information
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NPI Number | 1760927586
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Entity Type | Individual
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Provider Name | DEREIK LANCE DOMERESE LCSW
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Gender | Male
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Dates
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Enumeration Date | 01/03/2017
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Last Update Date | 06/15/2022
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Provider Practice Location Address
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Address Line | 905 NE RICE RD STE B
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City | LEES SUMMIT
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State | MO
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Zip | 64086-6300
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Country | US
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Telephone | 816-223-8522
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Fax |
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Provider Business Mailing Address
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Address Line | 2410 SW STATE ROUTE 150
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City | LEES SUMMIT
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State | MO
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Zip | 64082-2903
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Country | US
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Telephone | 816-223-8522
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 10198
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License Number State | KS
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 2016034259
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License Number State | MO
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