Healthcare Provider Details

I. General information

NPI: 1033323787
Provider Name (Legal Business Name): PETER FAJARDO SUBSTANCE ABUSE COUN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2385 PACIFIC AVENUE
LONG BEACH CA
90806
US

IV. Provider business mailing address

P.O. BOX 9463
LONG BEACH CA
90810
US

V. Phone/Fax

Practice location:
  • Phone: 562-336-1400
  • Fax: 562-336-1404
Mailing address:
  • Phone: 310-634-9039
  • Fax: 562-336-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: