Healthcare Provider Details

I. General information

NPI: 1396801957
Provider Name (Legal Business Name): MR. STANLEY JAMAR PRUITT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SOUTHERN AVE STE 1051
MESA AZ
85206-6205
US

IV. Provider business mailing address

922 E 10TH ST
MESA AZ
85203-5632
US

V. Phone/Fax

Practice location:
  • Phone: 480-493-0092
  • Fax:
Mailing address:
  • Phone: 619-370-8544
  • Fax: 480-641-5768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: