Healthcare Provider Details

I. General information

NPI: 1497472930
Provider Name (Legal Business Name): BREANNA PRUITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2022
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 S MASON RD
CREVE COEUR MO
63141-8029
US

IV. Provider business mailing address

265 LONE OAK DR APT F
SAINT CLAIR MO
63077-3212
US

V. Phone/Fax

Practice location:
  • Phone: 636-221-9495
  • Fax:
Mailing address:
  • Phone: 636-221-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-22-238978
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: