Provider Demographics
NPI:1023463650
Name:SHAZIER, TAYVON MICHELE
Entity type:Individual
Prefix:
First Name:TAYVON
Middle Name:MICHELE
Last Name:SHAZIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14195 MONTVIEW BLVD APT 14
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80011-4274
Mailing Address - Country:US
Mailing Address - Phone:303-748-7049
Mailing Address - Fax:
Practice Address - Street 1:14195 MONTVIEW BLVD
Practice Address - Street 2:APT 14
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-4289
Practice Address - Country:US
Practice Address - Phone:303-748-7049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO091630512320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO412168284OtherKAISER PERMANENTE