Provider Demographics
NPI:1265947287
Name:PEAL, TATIANA
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:PEAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 RUSSELL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2605
Mailing Address - Country:US
Mailing Address - Phone:301-330-0006
Mailing Address - Fax:301-330-0444
Practice Address - Street 1:702 RUSSELL AVE STE 100
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2605
Practice Address - Country:US
Practice Address - Phone:301-330-0006
Practice Address - Fax:301-330-0444
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MD26663104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLMSW26663OtherSTATE BOARD OF SOCIAL WORK EXAMINERS