Provider Demographics
NPI:1386239291
Name:FAJARDO, JULIO C (CLINICAL MT)
Entity type:Individual
Prefix:
First Name:JULIO
Middle Name:C
Last Name:FAJARDO
Suffix:
Gender:M
Credentials:CLINICAL MT
Other - Prefix:
Other - First Name:JULIO
Other - Middle Name:
Other - Last Name:FAJARDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:219 BURROUGHS RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-3545
Mailing Address - Country:US
Mailing Address - Phone:203-545-2906
Mailing Address - Fax:
Practice Address - Street 1:219 BURROUGHS RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-3545
Practice Address - Country:US
Practice Address - Phone:203-545-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT008099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist