Provider Demographics
NPI:1922372770
Name:CISNEROZ, CAMILLE (PH D)
Entity Type:Individual
Prefix:
First Name:CAMILLE
Middle Name:
Last Name:CISNEROZ
Suffix:
Gender:F
Credentials:PH D
Other - Prefix:
Other - First Name:CAMILLE
Other - Middle Name:
Other - Last Name:CISNEROZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD, LPCC
Mailing Address - Street 1:15885 S HIGHWAY 28
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:NM
Mailing Address - Zip Code:88044-9406
Mailing Address - Country:US
Mailing Address - Phone:575-202-1394
Mailing Address - Fax:
Practice Address - Street 1:4201 CARLISLE BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4808
Practice Address - Country:US
Practice Address - Phone:575-202-1394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-25
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0187171101YP2500X
NM0118411101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54035376Medicaid