Healthcare Provider Details

I. General information

NPI: 1285703041
Provider Name (Legal Business Name): TIMOTHY LEONARD HALLER SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 10/06/2021
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 BLAISDELL AVE
RAVENA NY
12143
US

IV. Provider business mailing address

PO BOX 761
COEYMANS NY
12045-0761
US

V. Phone/Fax

Practice location:
  • Phone: 518-334-9546
  • Fax:
Mailing address:
  • Phone: 518-334-9546
  • Fax: 518-756-9546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number005527
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: