Healthcare Provider Details

I. General information

NPI: 1699836734
Provider Name (Legal Business Name): DIANA LYNN PRUITT LCSW, CCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/23/2020
Certification Date: 07/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 HIGHLAND AVE
IRONDALE AL
35210-1013
US

IV. Provider business mailing address

2302 HIGHLAND AVE
IRONDALE AL
35210-1013
US

V. Phone/Fax

Practice location:
  • Phone: 404-423-6262
  • Fax:
Mailing address:
  • Phone: 404-423-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW003433
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: