Provider Demographics
NPI:1679337653
Name:BALLAYAN, ROMEO JESUS (LCSW)
Entity Type:Individual
Prefix:
First Name:ROMEO
Middle Name:JESUS
Last Name:BALLAYAN
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 1:3704 WYCLIFF AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-2911
Mailing Address - Country:US
Mailing Address - Phone:347-605-0462
Mailing Address - Fax:
Practice Address - Street 1:2986 CHIPPER DR NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5705
Practice Address - Country:US
Practice Address - Phone:347-605-0462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW225951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical