Healthcare Provider Details

I. General information

NPI: 1619112901
Provider Name (Legal Business Name): MARY LOUISE PRUITT CADC II,ICADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2008
Last Update Date: 05/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 ETHAN WAY STE 101
SACRAMENTO CA
95825-2225
US

IV. Provider business mailing address

1440 ETHAN WAY STE 101
SACRAMENTO CA
95825-2225
US

V. Phone/Fax

Practice location:
  • Phone: 916-922-9217
  • Fax:
Mailing address:
  • Phone: 916-922-9217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number03043920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: