Healthcare Provider Details

I. General information

NPI: 1174088769
Provider Name (Legal Business Name): WESLEY RYAN PRUITT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2019
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 PONTIAC ST
DENVER CO
80220-1831
US

IV. Provider business mailing address

1735 PONTIAC ST
DENVER CO
80220-1831
US

V. Phone/Fax

Practice location:
  • Phone: 405-413-7119
  • Fax:
Mailing address:
  • Phone: 405-413-7119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.0014168
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: