Provider Demographics
NPI:1093082380
Name:ROBERT J. CLEVELAND, LCSW, LLC
Entity Type:Organization
Organization Name:ROBERT J. CLEVELAND, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PSYCHOTHERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:860-652-5139
Mailing Address - Street 1:11 SADDLEGATE LANE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066
Mailing Address - Country:US
Mailing Address - Phone:860-652-5139
Mailing Address - Fax:866-704-3161
Practice Address - Street 1:39 NEW LONDON TURNPIKE
Practice Address - Street 2:SUITE 320
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033
Practice Address - Country:US
Practice Address - Phone:860-652-5139
Practice Address - Fax:866-704-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0059311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004265816Medicaid