MEDICARE: CHARLES JOSEPH MCNULTY LMT

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	225700000X	Massage Therapist	MT010389	GA

General Provider Information

NPI Number	:	1215736996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES JOSEPH MCNULTY LMT

Provider Business Mailing Address
First Line	:	789 HAMMOND DR APT 101
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-5590
Country	:	US
Telephone Number	:	251-599-7794
Fax Number	:

Provider Business Practice Location Address
First Line	:	6065 ROSWELL RD STE 170
Second Line	:
City	:	SANDY SPRINGS
State	:	GA
Zip	:	30328-4034
Country	:	US
Telephone Number	:	404-220-7770
Fax Number	:

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

Provider Enumeration Date	:	03/13/2025
Last Update Date	:	03/13/2025

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