Provider Demographics
NPI:1780241026
Name:CANALES FAJARDO, HELENA
Entity type:Individual
Prefix:
First Name:HELENA
Middle Name:
Last Name:CANALES 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 1:21466 SW 90TH PL
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33189-3765
Mailing Address - Country:US
Mailing Address - Phone:786-378-3027
Mailing Address - Fax:
Practice Address - Street 1:21466 SW 90TH PL
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33189-3765
Practice Address - Country:US
Practice Address - Phone:786-378-3027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18-67253106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty