Provider Demographics
NPI:1144992157
Name:LILLY, CAMERON MATTHEW
Entity type:Individual
Prefix:
First Name:CAMERON
Middle Name:MATTHEW
Last Name:LILLY
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 1:1836 ROSWELL ST SE APT 2104
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-2249
Mailing Address - Country:US
Mailing Address - Phone:614-867-6991
Mailing Address - Fax:
Practice Address - Street 1:1836 ROSWELL ST SE APT 2104
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-2249
Practice Address - Country:US
Practice Address - Phone:614-867-6991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-29
Last Update Date:2025-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0018262255A2300X
GAAT0043622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer