Provider Demographics
NPI:1124724000
Name:HEUSTIS, CAMERON
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:HEUSTIS
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 1:204 SARANAC LN
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3842
Mailing Address - Country:US
Mailing Address - Phone:304-989-2424
Mailing Address - Fax:
Practice Address - Street 1:124 CAPULET DR STE 102
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-4538
Practice Address - Country:US
Practice Address - Phone:904-429-3859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH232-103-00-017-0Medicaid