Basic Information
| Provider Information | |||||||||
| NPI: | 1609005024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CISNEROS | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1101 E 78TH ST | ||||||||
| Address2: | SUITE 318 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554201400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528847353 | ||||||||
| FaxNumber: | 9528849684 | ||||||||
| Practice Location | |||||||||
| Address1: | 1101 E 78TH ST | ||||||||
| Address2: | SUITE 318 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554201400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528847353 | ||||||||
| FaxNumber: | 9528849684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2009 | ||||||||
| LastUpdateDate: | 07/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 15805 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.