Provider Demographics
NPI:1962633552
Name:HALLBERG, KOIKI XAN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KOIKI
Middle Name:XAN
Last Name:HALLBERG
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:ORTONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48462-8536
Mailing Address - Country:US
Mailing Address - Phone:248-627-2177
Mailing Address - Fax:
Practice Address - Street 1:1999 OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MI
Practice Address - Zip Code:48462-8536
Practice Address - Country:US
Practice Address - Phone:248-627-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-31
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004539225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist