1629397492 NPI number — MS. JUDITH DIANNE CLEVELAND PH.D.

Table of content: MS. JUDITH DIANNE CLEVELAND PH.D. (NPI 1629397492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629397492 NPI number — MS. JUDITH DIANNE CLEVELAND PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLEVELAND
Provider First Name:
JUDITH
Provider Middle Name:
DIANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629397492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
259 HIGHWAY 74 N
Provider Second Line Business Mailing Address:
SUITE ONE
Provider Business Mailing Address City Name:
PEACHTREE CITY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30269-3561
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-630-0071
Provider Business Mailing Address Fax Number:
770-599-3033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 HIGHWAY 74 N
Provider Second Line Business Practice Location Address:
SUITE ONE
Provider Business Practice Location Address City Name:
PEACHTREE CITY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30269-3561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-630-0071
Provider Business Practice Location Address Fax Number:
770-599-3033
Provider Enumeration Date:
05/19/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  000129 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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