Provider Demographics
NPI:1881870921
Name:SHABAZZ, ADRIENNE MARIE (LBSW)
Entity type:Individual
Prefix:MS
First Name:ADRIENNE
Middle Name:MARIE
Last Name:SHABAZZ
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:N/A
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:N/A
Mailing Address - Street 1:PO BOX 8212
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0212
Mailing Address - Country:US
Mailing Address - Phone:817-789-0116
Mailing Address - Fax:
Practice Address - Street 1:10129 S RACE ST
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-9417
Practice Address - Country:US
Practice Address - Phone:817-789-0116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-19
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25692171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX171M00000XMedicaid