Healthcare Provider Details

I. General information

NPI: 1043021884
Provider Name (Legal Business Name): CAMERON HALL OT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S MARION AVE
LAKE CITY FL
32025-5808
US

IV. Provider business mailing address

13020 N TELECOM PKWY
TEMPLE TERRACE FL
33637-0925
US

V. Phone/Fax

Practice location:
  • Phone: 386-719-2817
  • Fax: 813-257-0447
Mailing address:
  • Phone: 813-978-9700
  • Fax: 813-257-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT25852
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: