Healthcare Provider Details

I. General information

NPI: 1962843201
Provider Name (Legal Business Name): DIANA RAMIREZ FAJARDO LCSW, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA RAMIREZ B.A.

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 POTRERO GRANDE DR
MONTEREY PARK CA
91755-7430
US

IV. Provider business mailing address

340 W 78TH ST
LOS ANGELES CA
90003-2414
US

V. Phone/Fax

Practice location:
  • Phone: 323-827-6529
  • Fax:
Mailing address:
  • Phone: 323-376-4710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number85008
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-25503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: