Provider Demographics
NPI:1770013922
Name:BELLAMY, SHAKEE
Entity Type:Individual
Prefix:
First Name:SHAKEE
Middle Name:
Last Name:BELLAMY
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 1:701 JEFFERSON AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-6957
Mailing Address - Country:US
Mailing Address - Phone:419-214-5511
Mailing Address - Fax:
Practice Address - Street 1:701 JEFFERSON AVE STE 301
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43604-6957
Practice Address - Country:US
Practice Address - Phone:419-214-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH344428488Medicaid