Provider Demographics
NPI:1104171909
Name:IGLESIA, CHRISTINA T
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:T
Last Name:IGLESIA
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 1:2325 CLEMENT AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-7061
Mailing Address - Country:US
Mailing Address - Phone:510-629-6300
Mailing Address - Fax:
Practice Address - Street 1:2325 CLEMENT AVE
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-7061
Practice Address - Country:US
Practice Address - Phone:510-629-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8121Medicaid