Healthcare Provider Details

I. General information

NPI: 1619102100
Provider Name (Legal Business Name): ELIZABETH PRESTON CISNEROS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH PRESTON

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 09/07/2023
Certification Date: 09/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E BONITA AVE DEPT OF
POMONA CA
91767-1933
US

IV. Provider business mailing address

14788 OAK LEAF DR
EASTVALE CA
92880-1048
US

V. Phone/Fax

Practice location:
  • Phone: 909-596-7733
  • Fax:
Mailing address:
  • Phone: 909-573-6415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY 24603
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY 24603
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: