Healthcare Provider Details

I. General information

NPI: 1215341565
Provider Name (Legal Business Name): IMARA CISNEROS LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2014
Last Update Date: 11/16/2022
Certification Date: 11/16/2022
Deactivation Date: 05/26/2019
Reactivation Date: 06/25/2020

III. Provider practice location address

14842 SIPLIN RD
WINTER GARDEN FL
34787-5101
US

IV. Provider business mailing address

14842 SIPLIN RD
WINTER GARDEN FL
34787-5101
US

V. Phone/Fax

Practice location:
  • Phone: 407-770-8001
  • Fax:
Mailing address:
  • Phone: 407-770-8001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberIMH 12320
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 12320
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH19678
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: