Provider Demographics
NPI:1285218206
Name:PRUITT, SHAWN ANDERSON
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:ANDERSON
Last Name:PRUITT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14301 EWING AVE S
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55306-4885
Mailing Address - Country:US
Mailing Address - Phone:952-746-5350
Mailing Address - Fax:
Practice Address - Street 1:223 CENTER ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-3595
Practice Address - Country:US
Practice Address - Phone:952-746-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician