Healthcare Provider Details

I. General information

NPI: 1225507569
Provider Name (Legal Business Name): MICHELLE OTILIA CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2018
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 ATLANTIC AVE STE 101
ALAMEDA CA
94501-1188
US

IV. Provider business mailing address

1025 ATLANTIC AVE STE 101
ALAMEDA CA
94501-1188
US

V. Phone/Fax

Practice location:
  • Phone: 717-851-0328
  • Fax: 510-251-8120
Mailing address:
  • Phone: 510-328-7178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: