Provider Demographics
NPI:1033323787
Name:FAJARDO, PETER (SUBSTANCE ABUSE COUN)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:SUBSTANCE ABUSE COUN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 9463
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90810
Mailing Address - Country:US
Mailing Address - Phone:310-634-9039
Mailing Address - Fax:562-336-1404
Practice Address - Street 1:2385 PACIFIC AVENUE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806
Practice Address - Country:US
Practice Address - Phone:562-336-1400
Practice Address - Fax:562-336-1404
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9223101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)