Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP1600X | Pastoral Counselor |
NPI | 1124630348 |
---|---|
Provider Name | Miguel Fajardo |
First Address | Hawthorne, NJ 07506-2413 |
Second Address | Hawthorne, NJ 07506-2413 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2020 |
Last Update Date | 19/08/2020 |