Provider Demographics
NPI:1174216642
Name:SIMONS, CAMERON
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:SIMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 GRAND CONCOURSE APT 18X
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-2617
Mailing Address - Country:US
Mailing Address - Phone:914-318-6092
Mailing Address - Fax:
Practice Address - Street 1:141 W 28TH ST RM 301
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6115
Practice Address - Country:US
Practice Address - Phone:914-318-6092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028521225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist