Provider Demographics
NPI:1447508312
Name:CISNEROS, CAROLYNN
Entity type:Individual
Prefix:
First Name:CAROLYNN
Middle Name:
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 1:1728 MEMORIAL DRIVE EXT
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29651-5750
Mailing Address - Country:US
Mailing Address - Phone:864-421-7777
Mailing Address - Fax:
Practice Address - Street 1:1 CHICK SPRINGS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-4946
Practice Address - Country:US
Practice Address - Phone:864-421-7777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-26
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional