Healthcare Provider Details

I. General information

NPI: 1760386858
Provider Name (Legal Business Name): LISA MARIE NORWOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 LEGENDS DR APT 1406
CANTON GA
30114-1114
US

IV. Provider business mailing address

100 LEGENDS DR APT 1406
CANTON GA
30114-1114
US

V. Phone/Fax

Practice location:
  • Phone: 770-771-3180
  • Fax:
Mailing address:
  • Phone: 770-771-3180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA002821
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: