Healthcare Provider Details

I. General information

NPI: 1225868706
Provider Name (Legal Business Name): SUSANA CISNEROS MA, PLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E LAHARPE ST
KIRKSVILLE MO
63501-4520
US

IV. Provider business mailing address

900 E LAHARPE ST
KIRKSVILLE MO
63501-4520
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-1962
  • Fax: 660-665-3989
Mailing address:
  • Phone: 660-665-1962
  • Fax: 660-665-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2024030563
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: