Provider Demographics
NPI:1164411948
Name:CLEAVELAND, BONNIE FRALIX (PHD DBPP)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:FRALIX
Last Name:CLEAVELAND
Suffix:
Gender:F
Credentials:PHD DBPP
Other - Prefix:DR
Other - First Name:BONNIE
Other - Middle Name:LOUISE
Other - Last Name:CLEAVELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:PO BOX 31088
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-1088
Mailing Address - Country:US
Mailing Address - Phone:843-571-4005
Mailing Address - Fax:877-668-6051
Practice Address - Street 1:1173 SOUTHGATE DR
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4209
Practice Address - Country:US
Practice Address - Phone:843-571-4005
Practice Address - Fax:877-668-6051
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC666103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC680011358OtherRAILROAD MEDICARE
SC2050504OtherCIGNA
SC2050504OtherCIGNA