Provider Demographics
NPI:1548833932
Name:BAILEY, SHAWN DWAYNE JR
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:DWAYNE
Last Name:BAILEY
Suffix:JR
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 1:1708 CHANTILLY DR STE B
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2446
Mailing Address - Country:US
Mailing Address - Phone:925-651-4612
Mailing Address - Fax:
Practice Address - Street 1:1708 CHANTILLY DR
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-2446
Practice Address - Country:US
Practice Address - Phone:985-651-4612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LABH001207Medicaid