MEDICARE: YARDAN SHABAZZ II RBT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1306673082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YARDAN SHABAZZ II RBT

Provider Business Mailing Address
First Line	:	429 CAROLINA AVE
Second Line	:
City	:	VA BEACH
State	:	VA
Zip	:	23451-4604
Country	:	US
Telephone Number	:	757-685-1384
Fax Number	:	757-210-4103

Provider Business Practice Location Address
First Line	:	429 CAROLINA AVE
Second Line	:
City	:	VA BEACH
State	:	VA
Zip	:	23451-4604
Country	:	US
Telephone Number	:	757-685-1384
Fax Number	:	757-210-4103

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2024
Last Update Date	:	09/17/2024

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