Provider Demographics
NPI:1295239390
Name:SHABAZZ, GEORGE KENYON
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:KENYON
Last Name:SHABAZZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8000 GOLDEN RING WAY
Mailing Address - Street 2:
Mailing Address - City:ANTELOPE
Mailing Address - State:CA
Mailing Address - Zip Code:95843-6125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1325 HOWE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3364
Practice Address - Country:US
Practice Address - Phone:916-676-0488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician