Provider Demographics
NPI:1285703041
Name:HALLER, TIMOTHY LEONARD (SLP)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEONARD
Last Name:HALLER
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:COEYMANS
Mailing Address - State:NY
Mailing Address - Zip Code:12045-0761
Mailing Address - Country:US
Mailing Address - Phone:518-334-9546
Mailing Address - Fax:518-756-9546
Practice Address - Street 1:47 BLAISDELL AVE
Practice Address - Street 2:
Practice Address - City:RAVENA
Practice Address - State:NY
Practice Address - Zip Code:12143
Practice Address - Country:US
Practice Address - Phone:518-334-9546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005527235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist