MEDICARE: MRS. TRACY PRUITT LMHCA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	88001983A	IN

General Provider Information

NPI Number	:	1083393060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TRACY PRUITT LMHCA

Provider Business Mailing Address
First Line	:	1213 BEDFORD DR
Second Line	:
City	:	AVON
State	:	IN
Zip	:	46123-5568
Country	:	US
Telephone Number	:	317-506-2783
Fax Number	:

Provider Business Practice Location Address
First Line	:	1311 W 96TH ST STE 265
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1344
Country	:	US
Telephone Number	:	317-500-2201
Fax Number	:	317-297-2600

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2023
Last Update Date	:	07/17/2023

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