Provider Demographics
NPI:1700253317
Name:CISNEROS, BRENDA JEANETTE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JEANETTE
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14500 ROSCOE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-4194
Mailing Address - Country:US
Mailing Address - Phone:800-764-8981
Mailing Address - Fax:
Practice Address - Street 1:14500 ROSCOE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4194
Practice Address - Country:US
Practice Address - Phone:800-764-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 104100000X
CAASW73239104100000X
CALCSW1076941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker