Provider Demographics
NPI:1457628604
Name:FAJARDO, YOHAIRA M (MA)
Entity Type:Individual
Prefix:
First Name:YOHAIRA
Middle Name:M
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:YOHAIRA
Other - Middle Name:M
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:13133 ORANGE GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-8422
Mailing Address - Country:US
Mailing Address - Phone:561-856-5620
Mailing Address - Fax:
Practice Address - Street 1:2101 VISTA PKWY STE 235
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-2706
Practice Address - Country:US
Practice Address - Phone:561-856-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2019-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
FLMH17217101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015925800Medicaid