MEDICARE: ELIZABETH FAJARDO M.A., BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1245772789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH FAJARDO M.A., BCBA

Provider Business Mailing Address
First Line	:	611 ROCKMEAD DR STE 100
Second Line	:
City	:	KINGWOOD
State	:	TX
Zip	:	77339-2294
Country	:	US
Telephone Number	:	281-793-8980
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 ROCKMEAD DR STE 100
Second Line	:
City	:	KINGWOOD
State	:	TX
Zip	:	77339-2294
Country	:	US
Telephone Number	:	281-793-8980
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2016
Last Update Date	:	11/15/2016

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