Provider Demographics
NPI:1518699776
Name:FAJARDO, BRANDY (SUDC)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:SUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7373 BROADWAY APT 205
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-1548
Mailing Address - Country:US
Mailing Address - Phone:619-822-9455
Mailing Address - Fax:
Practice Address - Street 1:220 EUCLID AVE STE 40
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3617
Practice Address - Country:US
Practice Address - Phone:619-727-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA11677101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)