Provider Demographics
NPI:1083228027
Name:CISNEROS, LEANDRO MANUEL SR
Entity Type:Individual
Prefix:MR
First Name:LEANDRO
Middle Name:MANUEL
Last Name:CISNEROS
Suffix:SR
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 1:3555 W 10TH AVE APT 301
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5178
Mailing Address - Country:US
Mailing Address - Phone:786-781-6524
Mailing Address - Fax:
Practice Address - Street 1:3555 W 10TH AVE APT 301
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-5178
Practice Address - Country:US
Practice Address - Phone:786-781-6524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19102066106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104838300Medicaid