Provider Demographics
NPI:1083350854
Name:PRUITT, NATHAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:
Last Name:PRUITT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 CHERRYVALE BLVD
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-9371
Mailing Address - Country:US
Mailing Address - Phone:518-390-3283
Mailing Address - Fax:
Practice Address - Street 1:15 CHERRYVALE BLVD
Practice Address - Street 2:
Practice Address - City:SLINGERLANDS
Practice Address - State:NY
Practice Address - Zip Code:12159-9371
Practice Address - Country:US
Practice Address - Phone:518-390-3283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019125103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist