Provider Demographics
NPI:1457076739
Name:SHABAZZ, OSAZE
Entity type:Individual
Prefix:
First Name:OSAZE
Middle Name:
Last Name:SHABAZZ
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:PO BOX 20379
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30325-0379
Mailing Address - Country:US
Mailing Address - Phone:678-756-4164
Mailing Address - Fax:
Practice Address - Street 1:2823 MOUNT WILKINSON PKWY SE # 13
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3631
Practice Address - Country:US
Practice Address - Phone:678-756-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-10
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health