Provider Demographics
NPI:1598218505
Name:FAJARDO, DIANA M
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:M
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 1:15306 SW 72ND ST
Mailing Address - Street 2:APT 11
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33193-1638
Mailing Address - Country:US
Mailing Address - Phone:786-514-3824
Mailing Address - Fax:
Practice Address - Street 1:14951 SW 75TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33193-2396
Practice Address - Country:US
Practice Address - Phone:786-514-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-15-07252106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician