Provider Demographics
NPI:1528808565
Name:FAJARDO, DIANA P (PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:P
Last Name:FAJARDO
Suffix:
Gender:F
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-2416
Mailing Address - Country:US
Mailing Address - Phone:929-580-3082
Mailing Address - Fax:
Practice Address - Street 1:1372 SUMMER ST STE 200
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5361
Practice Address - Country:US
Practice Address - Phone:203-539-0133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No171400000XOther Service ProvidersHealth & Wellness Coach
No101Y00000XBehavioral Health & Social Service ProvidersCounselor