Provider Demographics
NPI:1568730208
Name:CISNEROS, JUSTINE ALEECE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ALEECE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 E BISHOP DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-2915
Mailing Address - Country:US
Mailing Address - Phone:480-980-3914
Mailing Address - Fax:
Practice Address - Street 1:25615 N RANCH GATE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-2141
Practice Address - Country:US
Practice Address - Phone:480-221-7553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ#SLPA7568235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ#SLPA7568OtherSLPA/CERTIFICATION