Basic Information
| Provider Information | |||||||||
| NPI: | 1629212501 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLEVELAND | ||||||||
| FirstName: | BENICIA | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | MED, LAT, ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1250 S MARTIN LUTHER KING JR. DRIVE | ||||||||
| Address2: | WINSTON-SALEM STATE UNIVERSITY | ||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367502597 | ||||||||
| FaxNumber: | 3367508880 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 S MARTIN LUTHER KING JR. DRIVE | ||||||||
| Address2: | WINSTON-SALEM STATE UNIVERSITY | ||||||||
| City: | WINSTON-SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367502597 | ||||||||
| FaxNumber: | 3367508880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 1231 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.