Provider Demographics
NPI:1801660964
Name:CISNEROS, MARIANA OLGA (LCSW)
Entity type:Individual
Prefix:
First Name:MARIANA
Middle Name:OLGA
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3948 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2935
Mailing Address - Country:US
Mailing Address - Phone:773-388-1600
Mailing Address - Fax:773-388-8936
Practice Address - Street 1:3948 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2935
Practice Address - Country:US
Practice Address - Phone:773-388-1600
Practice Address - Fax:773-388-8936
Is Sole Proprietor?:No
Enumeration Date:2023-11-09
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490260721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149026072Medicaid