Provider Demographics
NPI:1447090626
Name:SAND, CAMERON Z (LMT, AOBTA-CP)
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:Z
Last Name:SAND
Suffix:
Gender:X
Credentials:LMT, AOBTA-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2239 N KIMBALL AVE UNIT 1F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3586
Mailing Address - Country:US
Mailing Address - Phone:609-320-0170
Mailing Address - Fax:
Practice Address - Street 1:1022 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-4102
Practice Address - Country:US
Practice Address - Phone:312-414-0058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.022495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist