MEDICARE: PATRICK P PRUITT LCSW

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	1041C0700X	Clinical Social Worker	2017042408	MO

General Provider Information

NPI Number	:	1356816631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICK P PRUITT LCSW

Provider Business Mailing Address
First Line	:	600 W 39TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64111-2910
Country	:	US
Telephone Number	:	816-421-7608
Fax Number	:	816-421-6493

Provider Business Practice Location Address
First Line	:	600 W 39TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64111-2910
Country	:	US
Telephone Number	:	816-421-7608
Fax Number	:	816-421-6493

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2018
Last Update Date	:	10/17/2018

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