Healthcare Provider Details

I. General information

NPI: 1073493904
Provider Name (Legal Business Name): CHRISTOPHER CISNEROS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 09/03/2025
Certification Date: 09/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 DICKSON DR STE 33
AUSTIN TX
78704-4788
US

IV. Provider business mailing address

2111 DICKSON DR STE 33
AUSTIN TX
78704-4788
US

V. Phone/Fax

Practice location:
  • Phone: 512-298-2257
  • Fax:
Mailing address:
  • Phone: 512-298-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number91860
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: