Provider Demographics
NPI:1508524505
Name:PERALTA, ELY ROMAN (LCSW-C, LICSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:ELY
Middle Name:ROMAN
Last Name:PERALTA
Suffix:
Gender:M
Credentials:LCSW-C, LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18213 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:OLNEY
Mailing Address - State:MD
Mailing Address - Zip Code:20832-1422
Mailing Address - Country:US
Mailing Address - Phone:301-417-5979
Mailing Address - Fax:
Practice Address - Street 1:18213 HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:MD
Practice Address - Zip Code:20832-1422
Practice Address - Country:US
Practice Address - Phone:301-417-5979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040164951041C0700X
DCLC2000032071041C0700X
MD272231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical