MEDICARE: SUSAN PRUITT HYDE LCSW

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	1041C0700X	Clinical Social Worker	57020	TX

General Provider Information

NPI Number	:	1497294250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN PRUITT HYDE LCSW

Provider Business Mailing Address
First Line	:	1975 BALLPARK WAY UNIT 202904
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76006-4523
Country	:	US
Telephone Number	:	817-264-6647
Fax Number	:

Provider Business Practice Location Address
First Line	:	2309 RAVENWOOD DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75050-2028
Country	:	US
Telephone Number	:	817-264-6647
Fax Number	:

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

Provider Enumeration Date	:	02/13/2017
Last Update Date	:	06/30/2022

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