Provider Demographics
NPI:1538273743
Name:PRUITT, MARK DUANE (LCSW)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:DUANE
Last Name:PRUITT
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4205 W GRANDVIEW RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-8276
Mailing Address - Country:US
Mailing Address - Phone:502-387-3668
Mailing Address - Fax:
Practice Address - Street 1:904 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-5812
Practice Address - Country:US
Practice Address - Phone:734-431-2166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1187104100000X
IN34003875A1041C0700X
MI68011151951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0644023Medicare ID - Type Unspecified