Healthcare Provider Details

I. General information

NPI: 1366174229
Provider Name (Legal Business Name): ELISEO CISNEROS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 ANTHONY DR
ANTHONY NM
88021-9317
US

IV. Provider business mailing address

385 CALLE DE ALEGRA STE A
LAS CRUCES NM
88005-3423
US

V. Phone/Fax

Practice location:
  • Phone: 575-201-5135
  • Fax: 575-449-4052
Mailing address:
  • Phone: 575-526-1105
  • Fax: 575-524-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberCTB-2024-0590
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: