Provider Demographics
NPI:1144919572
Name:SHABAZZ, ISIS (LMT)
Entity type:Individual
Prefix:
First Name:ISIS
Middle Name:
Last Name:SHABAZZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SAGE
Other - Middle Name:
Other - Last Name:SHABAZZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:5247 WILSON MILLS RD # 206
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143-3016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8803 BRECKSVILLE RD
Practice Address - Street 2:
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-1932
Practice Address - Country:US
Practice Address - Phone:216-952-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.025422225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist