Provider Demographics
NPI:1154075927
Name:PRUITT, VERONICA (LCSW-S)
Entity Type:Individual
Prefix:MS
First Name:VERONICA
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LCSW-S
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 15811
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76119-0811
Mailing Address - Country:US
Mailing Address - Phone:304-207-7717
Mailing Address - Fax:
Practice Address - Street 1:3136 EVANGELINE RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76140-8647
Practice Address - Country:US
Practice Address - Phone:304-207-7717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX628711041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical