MEDICARE: MS. LATEEFA ZAWI 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	104100000X	Social Worker	P017523	NC

General Provider Information

NPI Number	:	1811635998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LATEEFA ZAWI SHABAZZ

Provider Business Mailing Address
First Line	:	445 WESTERN BLVD STE Q
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6852
Country	:	US
Telephone Number	:	910-858-5848
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 COUNTRY CLUB RD APT 706
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-7309
Country	:	US
Telephone Number	:	317-469-3582
Fax Number	:

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

Provider Enumeration Date	:	05/26/2022
Last Update Date	:	05/26/2022

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