MEDICARE: MR. SALAAM AJALA SHABAZZ

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	106H00000X	Marriage & Family Therapist	81118	CA

General Provider Information

NPI Number	:	1811031289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SALAAM AJALA SHABAZZ

Provider Business Mailing Address
First Line	:	500 JEFFERSON BLVD
Second Line	:	SUITE B
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95605-2350
Country	:	US
Telephone Number	:	530-758-4078
Fax Number	:	916-287-4679

Provider Business Practice Location Address
First Line	:	500 JEFFERSON BLVD
Second Line	:	SUITE B
City	:	WEST SACRAMENTO
State	:	CA
Zip	:	95605-2350
Country	:	US
Telephone Number	:	530-758-4078
Fax Number	:	916-287-4679

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

Provider Enumeration Date	:	02/17/2007
Last Update Date	:	08/31/2015

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