Provider Demographics
NPI:1205442381
Name:CISNEROS, VANESSA (CLINICAL PSYCHOLOGIS)
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:CLINICAL PSYCHOLOGIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2010
Mailing Address - Country:US
Mailing Address - Phone:773-388-1600
Mailing Address - Fax:773-388-8864
Practice Address - Street 1:3533 W NORTH AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-7573
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8864
Is Sole Proprietor?:No
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.010344103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical