Provider Demographics
NPI:1083393060
Name:PRUITT, TRACY (LMHCA)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1213 BEDFORD DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-5568
Mailing Address - Country:US
Mailing Address - Phone:317-506-2783
Mailing Address - Fax:
Practice Address - Street 1:1311 W 96TH ST STE 265
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1344
Practice Address - Country:US
Practice Address - Phone:317-500-2201
Practice Address - Fax:317-297-2600
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88001983A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health