Provider Demographics
NPI:1023789484
Name:HALLER, STACY (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:HALLER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HARRISON ST, 7TH FL
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3429
Mailing Address - Country:US
Mailing Address - Phone:510-625-2856
Mailing Address - Fax:877-738-4262
Practice Address - Street 1:1040 TIERRA DEL REY STE 107
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7865
Practice Address - Country:US
Practice Address - Phone:619-500-5884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-25
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist