MEDICARE: SOULFRUIT PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1588526297
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOULFRUIT PLLC

Provider Business Mailing Address
First Line	:	5926 BAKER ST
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905-1945
Country	:	US
Telephone Number	:	910-691-7102
Fax Number	:

Provider Business Practice Location Address
First Line	:	5926 BAKER ST
Second Line	:
City	:	FORT BENNING
State	:	GA
Zip	:	31905-1945
Country	:	US
Telephone Number	:	910-691-7102
Fax Number	:

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

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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