Provider Demographics
NPI:1215552815
Name:FAJARDO, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:FAJARDO
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 1:18300 NW 82ND CT
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-2623
Mailing Address - Country:US
Mailing Address - Phone:786-351-4090
Mailing Address - Fax:
Practice Address - Street 1:18300 NW 82ND CT
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-2623
Practice Address - Country:US
Practice Address - Phone:786-351-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-10
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-122276106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst