Provider Demographics
NPI:1295611374
Name:PRUITT, DENNIS M SR
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
Last Name:PRUITT
Suffix:SR
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 1:390 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38004-7172
Mailing Address - Country:US
Mailing Address - Phone:901-900-0281
Mailing Address - Fax:
Practice Address - Street 1:390 THOMAS ST
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:TN
Practice Address - Zip Code:38004-7172
Practice Address - Country:US
Practice Address - Phone:901-900-0281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-13
Last Update Date:2025-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 104100000X, 171M00000X, 103K00000X, 101YP1600X, 101200000X, 101YS0200X, 106H00000X, 183700000X
TN4492376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101200000XBehavioral Health & Social Service ProvidersDrama TherapistGroup - Multi-Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty