Provider Demographics
NPI:1215492053
Name:CLEVELAND, JUSTINE
Entity type:Individual
Prefix:
First Name:JUSTINE
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 1:242031 COUNTY ROAD Y
Mailing Address - Street 2:
Mailing Address - City:ANIWA
Mailing Address - State:WI
Mailing Address - Zip Code:54408-5047
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:242031 COUNTY ROAD Y
Practice Address - Street 2:
Practice Address - City:ANIWA
Practice Address - State:WI
Practice Address - Zip Code:54408-5047
Practice Address - Country:US
Practice Address - Phone:715-297-8745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-06
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9124123104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker