MEDICARE: TYRA FAYE NORWOOD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225400000X	Rehabilitation Practitioner
2	106H00000X	Marriage & Family Therapist	118075	CA

General Provider Information

NPI Number	:	1184254815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA FAYE NORWOOD

Provider Business Mailing Address
First Line	:	8750 S VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044-4830
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8750 S VERMONT AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90044-4830
Country	:	US
Telephone Number	:	323-751-3026
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/24/2022

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