Healthcare Provider Details

I. General information

NPI: 1386403673
Provider Name (Legal Business Name): FRUITFUL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 03/18/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 EAST AMERIGE AVE
FULLERTON CA
92832
US

IV. Provider business mailing address

14271 JEFFREY RD # 296
IRVINE CA
92620-3405
US

V. Phone/Fax

Practice location:
  • Phone: 714-340-5941
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: JANIE LAI
Title or Position: PRESIDENT
Credential:
Phone: 714-340-5941