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General NPI Number Information
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NPI Number | 1255814851
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Entity Type | Individual
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Provider Name | REVONDA KISER PRUITT MS CCC-SLP
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Gender | Female
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Dates
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Enumeration Date | 09/10/2018
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Last Update Date | 09/10/2018
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Provider Practice Location Address
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Address Line | 502 W HOOD ST
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City | PIEDMONT
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State | AL
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Zip | 36272-1530
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Country | US
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Telephone | 256-447-9481
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Fax |
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Provider Business Mailing Address
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Address Line | 11310 US HIGHWAY 278 E
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City | PIEDMONT
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State | AL
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Zip | 36272-8365
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Country | US
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Telephone | 256-310-9352
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 1685
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License Number State | AL
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