Provider Demographics
NPI:1548743842
Name:HALLER, ASHLEY NICOLE (CTRS)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:HALLER
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 INDIAN HEAD DR
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-1703
Mailing Address - Country:US
Mailing Address - Phone:631-793-4429
Mailing Address - Fax:
Practice Address - Street 1:225 BROADHOLLOW RD STE 402
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4899
Practice Address - Country:US
Practice Address - Phone:631-385-7760
Practice Address - Fax:631-385-7795
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY66289225800000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist