Provider Demographics
NPI:1760587810
Name:CISNEROS, MARK GERARD (MFT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GERARD
Last Name:CISNEROS
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 CORNERSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92880-5488
Mailing Address - Country:US
Mailing Address - Phone:951-898-8799
Mailing Address - Fax:
Practice Address - Street 1:9990 COUNTY FARM RD
Practice Address - Street 2:SUITE5
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3542
Practice Address - Country:US
Practice Address - Phone:951-358-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42791106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist