MEDICARE: DEYSI CAROLINA CISNEROS GUTIERREZ BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-21-52473	CA

General Provider Information

NPI Number	:	1518635853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEYSI CAROLINA CISNEROS GUTIERREZ BCBA

Provider Business Mailing Address
First Line	:	5909 CARROTWOOD AVE
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93313-9462
Country	:	US
Telephone Number	:	661-912-3956
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 CALIFORNIA AVE STE 100A
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93309-7027
Country	:	US
Telephone Number	:	661-843-1930
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2021
Last Update Date	:	09/01/2021

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