Provider Demographics
NPI:1174072367
Name:CISNEROS, GLADYS (MS)
Entity type:Individual
Prefix:MS
First Name:GLADYS
Middle Name:
Last Name:CISNEROS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 KITTY HAWK RD
Mailing Address - Street 2:SUITE 219
Mailing Address - City:UNIVERSAL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78148-3357
Mailing Address - Country:US
Mailing Address - Phone:210-566-1280
Mailing Address - Fax:210-579-8533
Practice Address - Street 1:433 KITTY HAWK RD
Practice Address - Street 2:SUITE 219
Practice Address - City:UNIVERSAL CITY
Practice Address - State:TX
Practice Address - Zip Code:78148-3357
Practice Address - Country:US
Practice Address - Phone:210-566-1280
Practice Address - Fax:210-579-8533
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70362101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional