Provider Demographics
NPI:1609005024
Name:CISNEROS, KATRINA S (LICSW)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:S
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 E 78TH ST
Mailing Address - Street 2:SUITE 318
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-1400
Mailing Address - Country:US
Mailing Address - Phone:952-884-7353
Mailing Address - Fax:952-884-9684
Practice Address - Street 1:1101 E 78TH ST
Practice Address - Street 2:SUITE 318
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-1400
Practice Address - Country:US
Practice Address - Phone:952-884-7353
Practice Address - Fax:952-884-9684
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN158051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical