=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093082380
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT J. CLEVELAND, LCSW, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2011
-----------------------------------------------------
Last Update Date | 11/30/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 NEW LONDON TURNPIKE SUITE 320
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-652-5139
-----------------------------------------------------
Fax | 866-704-3161
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 SADDLEGATE LANE
-----------------------------------------------------
City | VERNON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-652-5139
-----------------------------------------------------
Fax | 866-704-3161
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PSYCHOTHERAPIST
-----------------------------------------------------
Name | MR. ROBERT J CLEVELAND
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 860-652-5139
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 005931
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------