Provider Demographics
NPI:1467534412
Name:CISNEROS, STEPHANIE W (PT)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:W
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:503-567-2732
Practice Address - Street 1:14603 SW TEAL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-6194
Practice Address - Country:US
Practice Address - Phone:971-709-7193
Practice Address - Fax:503-567-2732
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7438225100000X, 2251X0800X
WAPT608399242251H1200X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830004OtherMEDICARE NSC PV
AZ5550830008OtherMEDICARE NSC SWV
AZ5550830001OtherMEDICARE NSC SCW
AZ5550830009OtherMEDICARE NSC AZ NORTH
AZ5550830007OtherMEDICARE NSC DV
AZ5550830010OtherMEDICARE NSC GILBERT
AZ5550830006OtherMEDICARE NSC ANTHEM