Healthcare Provider Details

I. General information

NPI: 1790955375
Provider Name (Legal Business Name): RICHARD CASTILLO FAJARDO MA, LPCC, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GOLD AVE SW FL 11
ALBUQUERQUE NM
87102-3118
US

IV. Provider business mailing address

6884 AUGUSTA HILLS DR NE
RIO RANCHO NM
87144-8605
US

V. Phone/Fax

Practice location:
  • Phone: 505-385-4284
  • Fax: 505-248-7298
Mailing address:
  • Phone: 505-385-4284
  • Fax: 505-248-7298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0074081
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: