Healthcare Provider Details

I. General information

NPI: 1679337653
Provider Name (Legal Business Name): ROMEO JESUS BALLAYAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2024
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2986 CHIPPER DR NE
PALM BAY FL
32905-5705
US

IV. Provider business mailing address

3704 WYCLIFF AVE APT 3
DALLAS TX
75219-2911
US

V. Phone/Fax

Practice location:
  • Phone: 347-605-0462
  • Fax:
Mailing address:
  • Phone: 347-605-0462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW22595
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number112627
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: