Provider Demographics
NPI:1679638365
Name:CISNE, RANDY M (LMHC)
Entity Type:Individual
Prefix:MS
First Name:RANDY
Middle Name:M
Last Name:CISNE
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4161 TAMIAMI TRL STE 304D
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-9254
Mailing Address - Country:US
Mailing Address - Phone:941-625-5895
Mailing Address - Fax:941-625-1047
Practice Address - Street 1:4161 TAMIAMI TRL STE 304D
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9254
Practice Address - Country:US
Practice Address - Phone:941-625-5895
Practice Address - Fax:941-625-1047
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-25
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6079101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL116480100Medicaid