Healthcare Provider Details

I. General information

NPI: 1578019204
Provider Name (Legal Business Name): MIGNON PRUITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

741 EAST 75TH STREET
CHICAGO IL
60619-1928
US

IV. Provider business mailing address

17125 BERNADINE STREET
LANSING IL
60438-1473
US

V. Phone/Fax

Practice location:
  • Phone: 773-891-3242
  • Fax: 312-874-7219
Mailing address:
  • Phone: 773-671-1389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number149006136
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149006136
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149006136
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: