Provider Demographics
NPI:1619102100
Name:CISNEROS, ELIZABETH PRESTON (PHD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:PRESTON
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:PRESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14788 OAK LEAF DR
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-1048
Mailing Address - Country:US
Mailing Address - Phone:909-573-6415
Mailing Address - Fax:
Practice Address - Street 1:255 E BONITA AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1933
Practice Address - Country:US
Practice Address - Phone:909-596-7733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24603103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHD520AMedicare PIN