Healthcare Provider Details

I. General information

NPI: 1588526297
Provider Name (Legal Business Name): SOULFRUIT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5926 BAKER ST
FORT BENNING GA
31905-1945
US

IV. Provider business mailing address

5926 BAKER ST
FORT BENNING GA
31905-1945
US

V. Phone/Fax

Practice location:
  • Phone: 910-691-7102
  • Fax:
Mailing address:
  • Phone: 910-691-7102
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. EBONI DIANE HIL
Title or Position: OWNER , COUNSELOR
Credential: LCMHCA NCC
Phone: 910-691-7102