Provider Demographics
NPI:1629397492
Name:CLEVELAND, JUDITH DIANNE (PHD)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:DIANNE
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 HIGHWAY 74 N
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-3561
Mailing Address - Country:US
Mailing Address - Phone:770-630-0071
Mailing Address - Fax:770-599-3033
Practice Address - Street 1:259 HIGHWAY 74 N
Practice Address - Street 2:SUITE ONE
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-3561
Practice Address - Country:US
Practice Address - Phone:770-630-0071
Practice Address - Fax:770-599-3033
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000129101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health