Healthcare Provider Details

I. General information

NPI: 1376389106
Provider Name (Legal Business Name): THE FRUIT OF THE SPIRIT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 W MEADOWVIEW RD STE 272
GREENSBORO NC
27407-3406
US

IV. Provider business mailing address

2216 W MEADOWVIEW RD STE 272
GREENSBORO NC
27407-3406
US

V. Phone/Fax

Practice location:
  • Phone: 336-554-5897
  • Fax: 336-500-8329
Mailing address:
  • Phone: 336-554-5897
  • Fax: 336-500-8329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: KADIATOU TOURE
Title or Position: PSYCHOTHERAPIST
Credential: PH.D., ED.,D., BCCP
Phone: 336-554-5897