Provider Demographics
NPI:1174180012
Name:PRUITT, TIFFANY ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:ANN
Other - Last Name:PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1107 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MO
Mailing Address - Zip Code:64759-1758
Mailing Address - Country:US
Mailing Address - Phone:417-682-5757
Mailing Address - Fax:417-682-5757
Practice Address - Street 1:210 S ELM ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3413
Practice Address - Country:US
Practice Address - Phone:417-684-2644
Practice Address - Fax:417-682-5757
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20210047801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical