Healthcare Provider Details

I. General information

NPI: 1104333129
Provider Name (Legal Business Name): DAVID CISNEROS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11633 SAN VICENTE BLVD STE 300
LOS ANGELES CA
90049-6512
US

IV. Provider business mailing address

2503 NAPLES AVE
VENICE CA
90291-4947
US

V. Phone/Fax

Practice location:
  • Phone: 323-559-9637
  • Fax:
Mailing address:
  • Phone: 323-559-9637
  • Fax: 310-823-1506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: