Provider Demographics
NPI:1316310790
Name:CISNEROS, STACEY MICHELLE
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:MICHELLE
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 1:8401 JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3904
Mailing Address - Country:US
Mailing Address - Phone:916-453-1482
Mailing Address - Fax:916-453-1425
Practice Address - Street 1:8401 JACKSON RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-3904
Practice Address - Country:US
Practice Address - Phone:916-453-1482
Practice Address - Fax:916-453-1425
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker