Provider Demographics
NPI:1417675919
Name:WALLEY, CAMERON MACKENZIE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:CAMERON
Middle Name:MACKENZIE
Last Name:WALLEY
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7318 UNION RD
Mailing Address - Street 2:
Mailing Address - City:RICHTON
Mailing Address - State:MS
Mailing Address - Zip Code:39476-7813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 COLLEGE AVE STE A
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:AL
Practice Address - Zip Code:36545-2402
Practice Address - Country:US
Practice Address - Phone:251-744-5124
Practice Address - Fax:251-744-5170
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5940224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant