Provider Demographics
NPI:1487918231
Name:CIESINSKI, THEODORE (PHD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:CIESINSKI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 LUNALILO HOME ROAD
Mailing Address - Street 2:8228
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96825
Mailing Address - Country:US
Mailing Address - Phone:916-827-7319
Mailing Address - Fax:
Practice Address - Street 1:39180 LIBERTY ST STE 205
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2586
Practice Address - Country:US
Practice Address - Phone:916-827-7319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1867103T00000X
CA24868103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist