Healthcare Provider Details

I. General information

NPI: 1609005024
Provider Name (Legal Business Name): KATRINA S CISNEROS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2009
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST SUITE 318
BLOOMINGTON MN
55420-1400
US

IV. Provider business mailing address

1101 E 78TH ST SUITE 318
BLOOMINGTON MN
55420-1400
US

V. Phone/Fax

Practice location:
  • Phone: 952-884-7353
  • Fax: 952-884-9684
Mailing address:
  • Phone: 952-884-7353
  • Fax: 952-884-9684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15805
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: