Provider Demographics
NPI:1558866913
Name:CISNEROS, AMANDA ELISE (AMFT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:ELISE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 RESERVOIR DR STE 309
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5193
Mailing Address - Country:US
Mailing Address - Phone:888-588-8995
Mailing Address - Fax:510-756-0812
Practice Address - Street 1:5555 RESERVOIR DR STE 309
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5193
Practice Address - Country:US
Practice Address - Phone:888-588-8995
Practice Address - Fax:510-756-0812
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132697106H00000X
390200000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program