Provider Demographics
NPI:1144573791
Name:CLAVIJO, FABIAN R
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:R
Last Name:CLAVIJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 N VICTORIA DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-7143
Mailing Address - Country:US
Mailing Address - Phone:714-769-9026
Mailing Address - Fax:
Practice Address - Street 1:734 N VICTORIA DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-7143
Practice Address - Country:US
Practice Address - Phone:714-769-9026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90328106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist