| Good Fruit Tx Inc | |
|
1755 Park Street Suite 200 #1071 Naperville IL 60563 | |
| (815) 324-4367 | |
| Not Available |
| Full Name | Good Fruit Tx Inc |
|---|---|
| Speciality | Counselor |
| Location | 1755 Park Street Suite 200 #1071, Naperville, Illinois |
| Authorized Official Name and Position | Lashara Shaw (PROFESSIONAL COUNSELOR) |
| Authorized Official Contact | 8153244367 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Good Fruit Tx Inc Po Box 2041 Joliet IL 60434-2041 Ph: (815) 324-4367 | Good Fruit Tx Inc 1755 Park Street Suite 200 #1071 Naperville IL 60563 Ph: (815) 324-4367 |
| NPI Number | 1598342651 |
|---|---|
| Provider Enumeration Date | 03/25/2021 |
| Last Update Date | 03/25/2021 |
| Certification Date | 03/25/2021 |
| Medicare PECOS PAC ID | 6305295882 |
|---|---|
| Medicare Enrollment ID | O20231208002255 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598342651 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
| Provider Name | Lashara Shaw |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1972193936 PECOS PAC ID: 1052755287 Enrollment ID: I20240215003508 |
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