Healthcare Provider Details

I. General information

NPI: 1346324332
Provider Name (Legal Business Name): PHILIP CISNEROS-SEIBEL PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3734 6TH AVE
SAN DIEGO CA
92103-4317
US

IV. Provider business mailing address

845 FORT STOCKTON DR UNIT 514
SAN DIEGO CA
92103-6707
US

V. Phone/Fax

Practice location:
  • Phone: 302-128-7063
  • Fax:
Mailing address:
  • Phone: 330-212-8706
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number30970
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number4558
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: