Healthcare Provider Details

I. General information

NPI: 1649200924
Provider Name (Legal Business Name): MARY ALICE FRUIT PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 RAMSEY ST MENTAL HEALTH SERVICE LINE (116)
FAYETTEVILLE NC
28301-3856
US

IV. Provider business mailing address

5737 CHERRYSTONE RD
FAYETTEVILLE NC
28311-1374
US

V. Phone/Fax

Practice location:
  • Phone: 910-482-5078
  • Fax: 910-482-5099
Mailing address:
  • Phone: 910-480-0113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2082
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number2082
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2082
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number2082
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: