Provider Demographics
NPI:1629212501
Name:CLEVELAND, BENICIA ELAINE (MED, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:BENICIA
Middle Name:ELAINE
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:MED, LAT, ATC
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1250 S MARTIN LUTHER KING JR. DRIVE
Mailing Address - Street 2:WINSTON-SALEM STATE UNIVERSITY
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107
Mailing Address - Country:US
Mailing Address - Phone:336-750-2597
Mailing Address - Fax:336-750-8880
Practice Address - Street 1:1250 S MARTIN LUTHER KING JR. DRIVE
Practice Address - Street 2:WINSTON-SALEM STATE UNIVERSITY
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107
Practice Address - Country:US
Practice Address - Phone:336-750-2597
Practice Address - Fax:336-750-8880
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2011-09-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC12312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer