Healthcare Provider Details

I. General information

NPI: 1679638365
Provider Name (Legal Business Name): RANDY M CISNE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2006
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4161 TAMIAMI TRL STE 304D
PORT CHARLOTTE FL
33952-9254
US

IV. Provider business mailing address

4161 TAMIAMI TRL STE 304D
PORT CHARLOTTE FL
33952-9254
US

V. Phone/Fax

Practice location:
  • Phone: 941-625-5895
  • Fax: 941-625-1047
Mailing address:
  • Phone: 941-625-5895
  • Fax: 941-625-1047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH6079
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: