MEDICARE: LISA ANNE BLACKWOOD OT

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	225X00000X	Occupational Therapist	OT008480	GA
2	225X00000X	Occupational Therapist	113286	TX

General Provider Information

NPI Number	:	1902121486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANNE BLACKWOOD OT

Provider Business Mailing Address
First Line	:	1515 JOHNSON FERRY RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-6492
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 JOHNSON FERRY RD
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-6492
Country	:	US
Telephone Number	:	770-977-9457
Fax Number	:

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

Provider Enumeration Date	:	03/29/2010
Last Update Date	:	02/01/2024

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