Provider Demographics
NPI:1295898633
Name:FAJARDO, LILA DENISE (OTR)
Entity type:Individual
Prefix:
First Name:LILA
Middle Name:DENISE
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 N SILVER ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7415
Mailing Address - Country:US
Mailing Address - Phone:575-534-9110
Mailing Address - Fax:
Practice Address - Street 1:900 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:575-537-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3673225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM452Medicaid