Organization
MIND SHIELD AND SWORD THERAPY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DEREIK LANCE DOMERESE LCSW (OWNER/MEMBER)
(816) 223-8522
Entity
Organization
Contact information
Practice address
905 NE RICE RD STE B, LEES SUMMIT, MO 64086-6300
(816) 223-8522
Mailing address
2410 SW STATE ROUTE 150, LEES SUMMIT, MO 64082-2903
(816) 223-8522
Taxonomy
Speciality
Code
Description
License number
State
104100000X
Social Worker
—
—
1041C0700X
Clinical Social Worker
Primary
—
—
Other
Enumeration date
06/08/2022
Last updated
06/15/2022
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