Healthcare Provider Details

I. General information

NPI: 1538273743
Provider Name (Legal Business Name): MARK DUANE PRUITT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 02/22/2024
Certification Date: 02/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 HAWTHORNE AVE
YPSILANTI MI
48198-5812
US

IV. Provider business mailing address

4205 W GRANDVIEW RD
SALEM IN
47167-8276
US

V. Phone/Fax

Practice location:
  • Phone: 734-431-2166
  • Fax:
Mailing address:
  • Phone: 502-387-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1187
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003875A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801115195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: