MEDICARE: DR. BONNIE FRALIX CLEAVELAND PHD DBPP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	666	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	680011358	OTHER	SC	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	2050504	OTHER	SC	CIGNA

General Provider Information

NPI Number	:	1164411948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNIE FRALIX CLEAVELAND PHD DBPP

Provider Business Mailing Address
First Line	:	PO BOX 31088
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29417-1088
Country	:	US
Telephone Number	:	843-571-4005
Fax Number	:	877-668-6051

Provider Business Practice Location Address
First Line	:	1173 SOUTHGATE DR
Second Line	:	SUITE A
City	:	CHARLESTON
State	:	SC
Zip	:	29407-4209
Country	:	US
Telephone Number	:	843-571-4005
Fax Number	:	877-668-6051

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2005
Last Update Date	:	12/02/2008

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