Provider Demographics
NPI:1093352650
Name:SALGADO-CISNEROS, MAYOLA G (LSW)
Entity Type:Individual
Prefix:
First Name:MAYOLA
Middle Name:G
Last Name:SALGADO-CISNEROS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 CROSS CANYON LN
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-6268
Mailing Address - Country:US
Mailing Address - Phone:719-290-8081
Mailing Address - Fax:
Practice Address - Street 1:3136 CROSS CANYON LN
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-6268
Practice Address - Country:US
Practice Address - Phone:719-290-8081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLSW.0009922480104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
COMAYOLAGMedicaid