Provider Demographics
NPI:1649200924
Name:FRUIT, MARY ALICE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ALICE
Last Name:FRUIT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5737 CHERRYSTONE RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-1374
Mailing Address - Country:US
Mailing Address - Phone:910-480-0113
Mailing Address - Fax:
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:MENTAL HEALTH SERVICE LINE (116)
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:910-482-5078
Practice Address - Fax:910-482-5099
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2082103TA0700X, 103TC0700X, 103T00000X, 103TP2701X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy