Healthcare Provider Details

I. General information

NPI: 1558103143
Provider Name (Legal Business Name): BEN PRUITT LCSWA, MDIV
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5716 FAYETTEVILLE RD
DURHAM NC
27713-9661
US

IV. Provider business mailing address

5716 FAYETTEVILLE RD
DURHAM NC
27713-9661
US

V. Phone/Fax

Practice location:
  • Phone: 919-748-4610
  • Fax:
Mailing address:
  • Phone: 919-748-4610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP020716
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: