=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205988532
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDRE B PRUITT PH.D., MSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 06/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1220 SW MORRISON ST STE 730
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97205-2226
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-860-1213
-----------------------------------------------------
Fax | 503-988-3676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6926 NE 22ND AVE
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97211-5245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-860-1213
-----------------------------------------------------
Fax | 844-889-4937
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 3529
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------