Provider Demographics
NPI:1811635998
Name:SHABAZZ, LATEEFA ZAWI
Entity type:Individual
Prefix:MS
First Name:LATEEFA
Middle Name:ZAWI
Last Name:SHABAZZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 WESTERN BLVD STE Q
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6852
Mailing Address - Country:US
Mailing Address - Phone:910-858-5848
Mailing Address - Fax:
Practice Address - Street 1:2100 COUNTRY CLUB RD APT 706
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7309
Practice Address - Country:US
Practice Address - Phone:317-469-3582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP017523104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker