Provider Demographics
NPI:1659899441
Name:HALLER, PEGGY NOELLE (DAT, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:NOELLE
Last Name:HALLER
Suffix:
Gender:F
Credentials:DAT, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:407 RIDGEFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-2901
Mailing Address - Country:US
Mailing Address - Phone:804-350-2417
Mailing Address - Fax:
Practice Address - Street 1:1460 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-5195
Practice Address - Country:US
Practice Address - Phone:540-665-4566
Practice Address - Fax:540-665-4934
Is Sole Proprietor?:No
Enumeration Date:2017-09-01
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003345A2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN36003345AOtherINDIANA PROFESSIONAL LICENSING AGENCY
VA0126003755OtherVIRGINIA BOARD OF MEDICINE
2000038693OtherBOC CERTIFICATION