Provider Demographics
NPI:1063990752
Name:SHABAZZ, FATIMAH ZARIFAH
Entity type:Individual
Prefix:MRS
First Name:FATIMAH
Middle Name:ZARIFAH
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 1:16805 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-1453
Mailing Address - Country:US
Mailing Address - Phone:216-355-2713
Mailing Address - Fax:
Practice Address - Street 1:17325 EUCLID AVE STE 1105
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1247
Practice Address - Country:US
Practice Address - Phone:216-355-2713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH$$$$$$$$$Medicaid