Provider Demographics
NPI:1740633379
Name:SHABAZZ, ABDUL JALIL (MS)
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:JALIL
Last Name:SHABAZZ
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 RUSTLING REED RD
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-3539
Mailing Address - Country:US
Mailing Address - Phone:203-525-1265
Mailing Address - Fax:
Practice Address - Street 1:187 S CANAAN RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2544
Practice Address - Country:US
Practice Address - Phone:860-824-1397
Practice Address - Fax:888-764-6211
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional