=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508851494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG A. PRUITT LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2005
-----------------------------------------------------
Last Update Date | 03/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 404 W 2ND ST
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75455-3841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-577-1224
-----------------------------------------------------
Fax | 903-577-1810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 2060
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75456-2060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-577-1224
-----------------------------------------------------
Fax | 903-577-1810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 12774
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------