Healthcare Provider Details

I. General information

NPI: 1134920481
Provider Name (Legal Business Name): FRUIT BELT CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2025
Last Update Date: 03/22/2025
Certification Date: 03/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14804 OLD GALENA TRL
MOUNT CARROLL IL
61053-9037
US

IV. Provider business mailing address

2045 GRAND AVE STE B #952962
CHICAGO IL
60612-1577
US

V. Phone/Fax

Practice location:
  • Phone: 269-283-0014
  • Fax:
Mailing address:
  • Phone: 269-283-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: BAYLIE ROTH
Title or Position: EXECUTIVE DIRECTOR
Credential: LCSW
Phone: 630-750-2674