Provider Demographics
NPI:1902125099
Name:CISNEROS, DOLORES
Entity Type:Individual
Prefix:
First Name:DOLORES
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4224
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4224
Mailing Address - Country:US
Mailing Address - Phone:209-550-7444
Mailing Address - Fax:
Practice Address - Street 1:3300 TULLY RD
Practice Address - Street 2:SUITE D-5
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0836
Practice Address - Country:US
Practice Address - Phone:209-550-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05297101YP1600X
CA9319101YA0400X
CA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No174H00000XOther Service ProvidersHealth Educator