Provider Demographics
NPI:1275632242
Name:CLEVELAND, MARTIN ERVIN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:ERVIN
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Mailing Address - Street 2:650 JOEL DRIVE, BLDG E
Mailing Address - City:FT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5349
Mailing Address - Country:US
Mailing Address - Phone:270-798-4097
Mailing Address - Fax:
Practice Address - Street 1:BLANCHFIELD ARMY COMMUNITY HOSPITAL
Practice Address - Street 2:650 JOEL DRIVE, BLDG E
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5349
Practice Address - Country:US
Practice Address - Phone:270-798-4097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP 1078103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36822411Medicaid
TN4141240OtherBCBS OF TN
TN36822411Medicare PIN