Healthcare Provider Details

I. General information

NPI: 1518699776
Provider Name (Legal Business Name): BRANDY D. FAJARDO SUDRC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 EUCLID AVE STE 40
SAN DIEGO CA
92114-3617
US

IV. Provider business mailing address

220 EUCLID AVE STE 40
SAN DIEGO CA
92114-3617
US

V. Phone/Fax

Practice location:
  • Phone: 619-727-8921
  • Fax:
Mailing address:
  • Phone: 619-727-8921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11677
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: