Healthcare Provider Details

I. General information

NPI: 1801535968
Provider Name (Legal Business Name): GERALDA WHITE WULF BS, LMBT, CLT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2022
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2675 COURT DR
GASTONIA NC
28054-1478
US

IV. Provider business mailing address

2675 COURT DR
GASTONIA NC
28054-1478
US

V. Phone/Fax

Practice location:
  • Phone: 704-824-7800
  • Fax: 704-824-2822
Mailing address:
  • Phone: 704-824-7800
  • Fax: 704-824-2822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number02541
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: