Provider Demographics
NPI:1275723355
Name:PRUITT, ANGELA D (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANGELA
Middle Name:D
Last Name:PRUITT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 PIN OAK LOOP
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-6854
Mailing Address - Country:US
Mailing Address - Phone:501-454-0065
Mailing Address - Fax:
Practice Address - Street 1:47 PIN OAK LOOP
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-6854
Practice Address - Country:US
Practice Address - Phone:501-454-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6668-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical