Healthcare Provider Details

I. General information

NPI: 1417563362
Provider Name (Legal Business Name): CARLOS RUBEN CISNEROS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4040 N MARTIN L KING BLVD STE A
NORTH LAS VEGAS NV
89032-3205
US

IV. Provider business mailing address

4000 S EASTERN AVE STE 240
LAS VEGAS NV
89119-0847
US

V. Phone/Fax

Practice location:
  • Phone: 702-644-4673
  • Fax: 702-902-5443
Mailing address:
  • Phone: 702-799-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10518-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: