Provider Demographics
NPI:1760144125
Name:CLEVELAND, ADELINE
Entity Type:Individual
Prefix:
First Name:ADELINE
Middle Name:
Last Name:CLEVELAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 493
Mailing Address - Street 2:
Mailing Address - City:TESUQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87574-0493
Mailing Address - Country:US
Mailing Address - Phone:802-989-8067
Mailing Address - Fax:
Practice Address - Street 1:618 PASEO DE PERALTA STE A
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1984
Practice Address - Country:US
Practice Address - Phone:505-989-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT9402225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMMT9402OtherLMT LICENSE