Provider Demographics
NPI:1053644070
Name:PRUITT, KIMBERLEY LAYNE BENTON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEY
Middle Name:LAYNE BENTON
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:KIMBERLEY
Other - Middle Name:LAYNE
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:8506 SIX FORKS RD STE 104
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3260
Mailing Address - Country:US
Mailing Address - Phone:919-234-7247
Mailing Address - Fax:919-238-1970
Practice Address - Street 1:8506 SIX FORKS RD STE 104
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3260
Practice Address - Country:US
Practice Address - Phone:919-234-7247
Practice Address - Fax:919-238-1970
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-09
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5077103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty