Provider Demographics
NPI:1811031289
Name:SHABAZZ, SALAAM AJALA
Entity Type:Individual
Prefix:MR
First Name:SALAAM
Middle Name:AJALA
Last Name:SHABAZZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SEAN
Other - Middle Name:ANTHONY
Other - Last Name:PICKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:500 JEFFERSON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-2350
Mailing Address - Country:US
Mailing Address - Phone:530-758-4078
Mailing Address - Fax:916-287-4679
Practice Address - Street 1:500 JEFFERSON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-2350
Practice Address - Country:US
Practice Address - Phone:530-758-4078
Practice Address - Fax:916-287-4679
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81118106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist