Healthcare Provider Details

I. General information

NPI: 1659242311
Provider Name (Legal Business Name): MACIE CISNEROS LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W 16TH ST
PUEBLO CO
81003-2745
US

IV. Provider business mailing address

575 E FREDONIA DR
PUEBLO WEST CO
81007-5304
US

V. Phone/Fax

Practice location:
  • Phone: 719-595-7891
  • Fax:
Mailing address:
  • Phone: 719-595-7891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0022112
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: