Healthcare Provider Details

I. General information

NPI: 1902125099
Provider Name (Legal Business Name): DOLORES CISNEROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2010
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 TULLY RD SUITE D-5
MODESTO CA
95350-0836
US

IV. Provider business mailing address

PO BOX 4224
MODESTO CA
95352-4224
US

V. Phone/Fax

Practice location:
  • Phone: 209-550-7444
  • Fax:
Mailing address:
  • Phone: 209-550-7444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number05297
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number9319
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: