Provider Demographics
NPI:1467797118
Name:HALLER, MATTHIAS (COTA/L)
Entity Type:Individual
Prefix:
First Name:MATTHIAS
Middle Name:
Last Name:HALLER
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:451 BOARDWALK DR
Mailing Address - Street 2:APT 1118
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-3220
Mailing Address - Country:US
Mailing Address - Phone:614-309-9685
Mailing Address - Fax:
Practice Address - Street 1:451 BOARDWALK DR
Practice Address - Street 2:APT 1118
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-3220
Practice Address - Country:US
Practice Address - Phone:614-309-9685
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOTA.04763224Z00000X
TX211930224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD288650OtherNBCOT