Provider Demographics
NPI:1487151395
Name:FAJARDO PEREZ, GRETHEL (BC BA)
Entity type:Individual
Prefix:MRS
First Name:GRETHEL
Middle Name:
Last Name:FAJARDO PEREZ
Suffix:
Gender:F
Credentials:BC BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13930 SW 47TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-4400
Mailing Address - Country:US
Mailing Address - Phone:786-334-9155
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:13930 SW 47TH ST STE 203
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-4400
Practice Address - Country:US
Practice Address - Phone:865-347-1277
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-07
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-2157413103K00000X
FL0-19-10498106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty