Healthcare Provider Details

I. General information

NPI: 1407471543
Provider Name (Legal Business Name): VIVIAN FAJARDO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2020
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7865 W BELL RD # 1056
PEORIA AZ
85382-3803
US

IV. Provider business mailing address

7865 W BELL RD # 1056
PEORIA AZ
85382-3803
US

V. Phone/Fax

Practice location:
  • Phone: 602-825-3925
  • Fax:
Mailing address:
  • Phone: 602-825-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW-18599
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-18599
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: