Provider Demographics
NPI:1295722957
Name:CLEVELAND, LEE A (RD CDE)
Entity type:Individual
Prefix:MR
First Name:LEE
Middle Name:A
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W5008 GOLF COURSE RD
Mailing Address - Street 2:#604
Mailing Address - City:SHERWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54169-9723
Mailing Address - Country:US
Mailing Address - Phone:920-585-4961
Mailing Address - Fax:920-727-8001
Practice Address - Street 1:1550 MIDWAY PL
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1165
Practice Address - Country:US
Practice Address - Phone:920-585-4961
Practice Address - Fax:920-727-8001
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1864133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI050145300Medicare PIN
WI050371018Medicare PIN