Provider Demographics
NPI:1578971636
Name:CLEVELAND, BENJAMIN (ATC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43777 HUNTERS HILL DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-8938
Mailing Address - Country:US
Mailing Address - Phone:251-623-0135
Mailing Address - Fax:
Practice Address - Street 1:500 W UNIVERSITY ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2522
Practice Address - Country:US
Practice Address - Phone:405-585-5351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12612255A2300X
OK9112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer