Healthcare Provider Details

I. General information

NPI: 1174801732
Provider Name (Legal Business Name): FERNANDO CISNEROS L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2011
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3410 W ROOSEVELT RD
CHICAGO IL
60624-4343
US

IV. Provider business mailing address

1247 S 56TH CT
CICERO IL
60804-1213
US

V. Phone/Fax

Practice location:
  • Phone: 773-826-2929
  • Fax: 773-826-2964
Mailing address:
  • Phone: 708-296-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.01.4731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: