Healthcare Provider Details

I. General information

NPI: 1548743321
Provider Name (Legal Business Name): ROXANNE PRUITT-KISER LCSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2018
Last Update Date: 09/20/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 602ND ST BACH
FORT WAINWRIGHT AK
99703
US

IV. Provider business mailing address

BLDG 4060 602ND ST
FORT WAINWRIGHT AK
99703
US

V. Phone/Fax

Practice location:
  • Phone: 73-617-2039
  • Fax:
Mailing address:
  • Phone: 907-361-0229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC011676
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier32055
Identifier TypeOTHER
Identifier StateMN
Identifier IssuerLICSW
# 2
IdentifierC011676
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerLCSW

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: