Healthcare Provider Details

I. General information

NPI: 1922372770
Provider Name (Legal Business Name): CAMILLE CISNEROZ PH D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAMILLE CISNEROZ PHD, LPCC

II. Dates (important events)

Enumeration Date: 02/25/2012
Last Update Date: 01/13/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15885 S HIGHWAY 28
LA MESA NM
88044-9406
US

IV. Provider business mailing address

15885 S HIGHWAY 28
LA MESA NM
88044-9406
US

V. Phone/Fax

Practice location:
  • Phone: 575-202-1394
  • Fax:
Mailing address:
  • Phone: 575-202-1394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0187171
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: