Healthcare Provider Details

I. General information

NPI: 1578346987
Provider Name (Legal Business Name): BERTHA A FAJARDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3590 E IMPERIAL HWY
LYNWOOD CA
90262-2655
US

IV. Provider business mailing address

2088 S ATLANTIC BLVD STE 469
MONTEREY PARK CA
91754-6304
US

V. Phone/Fax

Practice location:
  • Phone: 323-201-4516
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number143969
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: