Provider Demographics
NPI:1144069089
Name:RISBY, SHALAMAR
Entity type:Individual
Prefix:
First Name:SHALAMAR
Middle Name:
Last Name:RISBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 BELLFLOWER AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-4052
Mailing Address - Country:US
Mailing Address - Phone:757-309-0149
Mailing Address - Fax:
Practice Address - Street 1:833 BELLFLOWER AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-4052
Practice Address - Country:US
Practice Address - Phone:757-309-0149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-21
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1144069089374U00000X, 376J00000X
385HR2060X, 251C00000X, 253Z00000X, 343900000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No253Z00000XAgenciesIn Home Supportive Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator