Provider Demographics
NPI:1477622561
Name:CAMERON, HEATHER NICOLE (OTR L)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:CAMERON
Suffix:
Gender:F
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 MONTICELLO PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-9273
Mailing Address - Country:US
Mailing Address - Phone:505-693-8190
Mailing Address - Fax:
Practice Address - Street 1:1600 SUTTER PL
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4611
Practice Address - Country:US
Practice Address - Phone:505-769-4490
Practice Address - Fax:505-935-0011
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1525225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM19325312Medicaid