=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174801732
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FERNANDO CISNEROS L.C.S.W.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2011
-----------------------------------------------------
Last Update Date | 08/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3410 W ROOSEVELT RD
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60624-4343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-826-2929
-----------------------------------------------------
Fax | 773-826-2964
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1247 S 56TH CT
-----------------------------------------------------
City | CICERO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60804-1213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-296-8787
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149.01.4731
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------