Healthcare Provider Details

I. General information

NPI: 1962388561
Provider Name (Legal Business Name): MATTHEW KUHNWALD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2025
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

955 MEMORIAL DR SE SUITE 522, LOFT 8
ATLANTA GA
30316
US

IV. Provider business mailing address

19 BURNT CREEK CT SW
LILBURN GA
30047-6207
US

V. Phone/Fax

Practice location:
  • Phone: 414-412-8204
  • Fax:
Mailing address:
  • Phone: 414-412-8204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015108
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: