Healthcare Provider Details

I. General information

NPI: 1205502416
Provider Name (Legal Business Name): ELIZABETH WUNDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6213 ROUND HILL RD
CHARLOTTE NC
28211-6268
US

IV. Provider business mailing address

6213 ROUND HILL RD
CHARLOTTE NC
28211-6268
US

V. Phone/Fax

Practice location:
  • Phone: 704-891-5377
  • Fax:
Mailing address:
  • Phone: 704-891-5377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11200
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: