Healthcare Provider Details

I. General information

NPI: 1669199378
Provider Name (Legal Business Name): FRUIT BELT COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 W MAPLE ST
KALAMAZOO MI
49008-1845
US

IV. Provider business mailing address

1207 W MAPLE ST
KALAMAZOO MI
49008-1845
US

V. Phone/Fax

Practice location:
  • Phone: 630-750-2674
  • Fax:
Mailing address:
  • Phone:
  • 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: DIRECTOR
Credential: LCSW
Phone: 630-750-2674