Provider Demographics
NPI:1235771106
Name:SHABAZZ, AHLAYAH DAVIANAH I
Entity Type:Individual
Prefix:MS
First Name:AHLAYAH
Middle Name:DAVIANAH
Last Name:SHABAZZ
Suffix:I
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:AHLAYAH
Other - Middle Name:D
Other - Last Name:SHABAZZ
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1025 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1189
Mailing Address - Country:US
Mailing Address - Phone:510-268-8120
Mailing Address - Fax:
Practice Address - Street 1:1025 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1189
Practice Address - Country:US
Practice Address - Phone:510-268-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2019-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXDJ95973531EMedicaid