Provider Demographics
NPI:1700183928
Name:CISNEROS, KARINA
Entity Type:Individual
Prefix:
First Name:KARINA
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KARINA
Other - Middle Name:
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5150 N 6TH ST STE 116
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-7505
Mailing Address - Country:US
Mailing Address - Phone:559-477-9244
Mailing Address - Fax:
Practice Address - Street 1:5070 N 6TH ST STE 105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-7504
Practice Address - Country:US
Practice Address - Phone:559-477-9244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CALCSW771641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1700183928Medicaid