Provider Demographics
NPI:1083150486
Name:PRUITT, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3143 PLUMWOOD LN
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-5184
Mailing Address - Country:US
Mailing Address - Phone:626-759-2636
Mailing Address - Fax:
Practice Address - Street 1:870 SIERRA VISTA DR STE 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89169-9364
Practice Address - Country:US
Practice Address - Phone:602-592-0503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst