Healthcare Provider Details

I. General information

NPI: 1902482730
Provider Name (Legal Business Name): KARLA MARIE HALDE ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 MEMORIAL DR
BELLEVILLE IL
62226-5399
US

IV. Provider business mailing address

6908 LOYET RD
COLLINSVILLE IL
62234-6520
US

V. Phone/Fax

Practice location:
  • Phone: 618-233-7750
  • Fax:
Mailing address:
  • Phone: 618-974-8489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.004582
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: