Provider Demographics
NPI:1023566080
Name:PRUITT, ELIZABETH (MED)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29372
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71149-9372
Mailing Address - Country:US
Mailing Address - Phone:318-670-8898
Mailing Address - Fax:
Practice Address - Street 1:9403 MANSFIELD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3815
Practice Address - Country:US
Practice Address - Phone:318-861-8938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health