Provider Demographics
NPI:1760927586
Name:DOMERESE, DEREIK LANCE (LCSW)
Entity Type:Individual
Prefix:
First Name:DEREIK
Middle Name:LANCE
Last Name:DOMERESE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 SW STATE ROUTE 150
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64082-2903
Mailing Address - Country:US
Mailing Address - Phone:816-223-8522
Mailing Address - Fax:
Practice Address - Street 1:905 NE RICE RD STE B
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64086-6300
Practice Address - Country:US
Practice Address - Phone:816-223-8522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-03
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS101981041C0700X
MO20160342591041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical