Provider Demographics
NPI:1346547429
Name:PRUITT, STACY (SLP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PRUITT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25221 MILES RD UNIT F
Mailing Address - Street 2:
Mailing Address - City:WARRENSVILLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44128-5494
Mailing Address - Country:US
Mailing Address - Phone:216-514-1600
Mailing Address - Fax:216-292-3291
Practice Address - Street 1:25221 MILES RD UNIT F
Practice Address - Street 2:
Practice Address - City:WARRENSVILLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44128-5494
Practice Address - Country:US
Practice Address - Phone:216-514-1600
Practice Address - Fax:216-292-3291
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-25
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-9821235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist