Basic Information
Provider Information
NPI: 1003140625
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HALLER
FirstName: KRISTA
MiddleName: N
NamePrefix: MS.
NameSuffix:  
Credential: M.A.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 702 RUTH AVE
Address2:  
City: SANDPOINT
State: ID
PostalCode: 838641956
CountryCode: US
TelephoneNumber: 5302623497
FaxNumber:  
Practice Location
Address1: 212 N 1ST AVE STE 203
Address2:  
City: SANDPOINT
State: ID
PostalCode: 83864
CountryCode: US
TelephoneNumber: 2089465242
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/29/2009
LastUpdateDate: 05/06/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YM0800XLPC-6456IDY Behavioral Health & Social Service ProvidersCounselorMental Health
106H00000X  N Behavioral Health & Social Service ProvidersMarriage & Family Therapist 

No ID Information.


Home