Basic Information
Provider Information | |||||||||
NPI: | 1649200924 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRUIT | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | ALICE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PSYD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5737 CHERRYSTONE RD | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283111374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9104800113 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2300 RAMSEY ST | ||||||||
Address2: | MENTAL HEALTH SERVICE LINE (116) | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283013856 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9104825078 | ||||||||
FaxNumber: | 9104825099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/03/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0700X | 2082 | NC | X |   | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 103TC0700X | 2082 | NC | X |   | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103T00000X | 2082 | NC | X |   | Behavioral Health & Social Service Providers | Psychologist |   | 103TP2701X | 2082 | NC | X |   | Behavioral Health & Social Service Providers | Psychologist | Group Psychotherapy |
No ID Information.