Healthcare Provider Details

I. General information

NPI: 1134084007
Provider Name (Legal Business Name): M. OLGA CISNEROS BRAVO PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1525 E 53RD ST STE 437
CHICAGO IL
60615-4575
US

IV. Provider business mailing address

1525 E 53RD ST STE 437
CHICAGO IL
60615-4575
US

V. Phone/Fax

Practice location:
  • Phone: 773-362-5305
  • Fax:
Mailing address:
  • Phone: 773-361-5305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MARIANA OLGA CISNEROS
Title or Position: THERAPIST
Credential: LCSW
Phone: 765-427-9817