Provider Demographics
NPI:1285251967
Name:SOMATIC REVELATIONS, LLC
Entity type:Organization
Organization Name:SOMATIC REVELATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:S
Authorized Official - Last Name:TEDMON-JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:307-200-9228
Mailing Address - Street 1:PO BOX 594
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82073-0594
Mailing Address - Country:US
Mailing Address - Phone:307-200-9228
Mailing Address - Fax:
Practice Address - Street 1:2020 E GRAND AVE STE 421 & 412
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4370
Practice Address - Country:US
Practice Address - Phone:307-200-9228
Practice Address - Fax:307-460-9084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance TherapistGroup - Multi-Specialty