Healthcare Provider Details

I. General information

NPI: 1093573735
Provider Name (Legal Business Name): EDDY HECTOR CISNEROS LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 GUADALUPE ST STE 260
AUSTIN TX
78705-5654
US

IV. Provider business mailing address

3230 HILLCREST DR APT 2208
SAN ANTONIO TX
78201-7099
US

V. Phone/Fax

Practice location:
  • Phone: 210-810-9024
  • Fax:
Mailing address:
  • Phone: 210-810-9024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number85375
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: