Provider Demographics
NPI:1861384513
Name:CISNEROS, EDUARDO J
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:J
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4824 N TRIPP AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-2721
Mailing Address - Country:US
Mailing Address - Phone:312-320-1971
Mailing Address - Fax:
Practice Address - Street 1:5 REVERE DR STE 200
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-8000
Practice Address - Country:US
Practice Address - Phone:312-600-3991
Practice Address - Fax:630-473-2232
Is Sole Proprietor?:No
Enumeration Date:2025-07-17
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041524344163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health