Provider Demographics
NPI:1194586347
Name:EJAZ, SHABNAM
Entity type:Individual
Prefix:
First Name:SHABNAM
Middle Name:
Last Name:EJAZ
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 1:814 FOXTAIL RUN
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-5043
Mailing Address - Country:US
Mailing Address - Phone:504-906-2375
Mailing Address - Fax:
Practice Address - Street 1:814 FOXTAIL RUN
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-5043
Practice Address - Country:US
Practice Address - Phone:504-906-2375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty