Provider Demographics
NPI:1235439860
Name:SHABAZZ, BASHEER AHMAD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BASHEER
Middle Name:AHMAD
Last Name:SHABAZZ
Suffix:
Gender:M
Credentials:LCSW
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 1901
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-0009
Mailing Address - Country:US
Mailing Address - Phone:908-296-0724
Mailing Address - Fax:
Practice Address - Street 1:654 E JERSEY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07206-1261
Practice Address - Country:US
Practice Address - Phone:908-296-0724
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ7926131041S0200X
NJ44SC055408001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0404845Medicaid