MEDICARE: MS. ADRIENNE MARIE SHABAZZ LBSW

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	171M00000X	Case Manager/Care Coordinator	25692	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1881870921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ADRIENNE MARIE SHABAZZ LBSW

Provider Business Mailing Address
First Line	:	PO BOX 8212
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76124-0212
Country	:	US
Telephone Number	:	817-789-0116
Fax Number	:

Provider Business Practice Location Address
First Line	:	10129 S RACE ST
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76140-9417
Country	:	US
Telephone Number	:	817-789-0116
Fax Number	:

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

Provider Enumeration Date	:	01/19/2008
Last Update Date	:	04/21/2023

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