Provider Demographics
NPI:1700668282
Name:EGGLESTON, HALLE MIRANDA
Entity Type:Individual
Prefix:
First Name:HALLE
Middle Name:MIRANDA
Last Name:EGGLESTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4457 W LA SIESTA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-5647
Mailing Address - Country:US
Mailing Address - Phone:417-755-0982
Mailing Address - Fax:
Practice Address - Street 1:636 W REPUBLIC RD STE C104
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5806
Practice Address - Country:US
Practice Address - Phone:417-507-2407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023042154101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional