Provider Demographics
NPI:1093917692
Name:PRUITT, MARIA ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ELIZABETH
Last Name:PRUITT
Suffix:
Gender:F
Credentials:PT
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 667744
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28266-7744
Mailing Address - Country:US
Mailing Address - Phone:704-860-0569
Mailing Address - Fax:704-392-4788
Practice Address - Street 1:414 W LEBANON ST
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-2954
Practice Address - Country:US
Practice Address - Phone:336-789-9041
Practice Address - Fax:336-789-9042
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11023225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11023OtherPHYSICAL THERAPIST