Provider Demographics
NPI:1215736996
Name:MCNULTY, CHARLES JOSEPH (LMT)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:JOSEPH
Last Name:MCNULTY
Suffix:
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 HAMMOND DR APT 101
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5590
Mailing Address - Country:US
Mailing Address - Phone:251-599-7794
Mailing Address - Fax:
Practice Address - Street 1:6065 ROSWELL RD STE 170
Practice Address - Street 2:
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-4034
Practice Address - Country:US
Practice Address - Phone:404-220-7770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT010389225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist