Provider Demographics
NPI:1144819996
Name:THE FULL FRUIT EMPOWERMENT CENTER
Entity type:Organization
Organization Name:THE FULL FRUIT EMPOWERMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO/ EXE DIR
Authorized Official - Prefix:MS
Authorized Official - First Name:DELORA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC-S, LCDC, SAP
Authorized Official - Phone:469-766-1251
Mailing Address - Street 1:1512 CHAMA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-2666
Mailing Address - Country:US
Mailing Address - Phone:469-766-1251
Mailing Address - Fax:
Practice Address - Street 1:4650 S HAMPTON RD STE 119
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-1061
Practice Address - Country:US
Practice Address - Phone:682-557-4695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty