Healthcare Provider Details

I. General information

NPI: 1679188643
Provider Name (Legal Business Name): JOHN IGLESIAS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 E MAIN ST
CLAYTON NC
27520-2626
US

IV. Provider business mailing address

5101 ISTRIAN WAY
RALEIGH NC
27610-7145
US

V. Phone/Fax

Practice location:
  • Phone: 919-737-7797
  • Fax:
Mailing address:
  • Phone: 561-756-0587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number20539
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: