Provider Demographics
NPI:1346411360
Name:CISNEROS, HENRY (PHD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:PHD
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?:No
Enumeration Date:2008-03-18
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool